What’s Happening: Advance Appropriations for the Indian Health Service

  • Advance Appropriations for the Indian Health Service is the most impactful policy that Congress can do for Native communities this year.
  • We can’t let our momentum fade during this critical time.
  • Now is the time to keep the pressure on Congress.

1 Big Thing: Congress has reached a deal on the omnibus

The Latest: Congressional leaders agreed to a government funding framework for a year-end omnibus spending package. (Top appropriators clinch deal on government funding framework)

What’s next: This week, Congress is finalizing the details of the framework, and it’s important that Congress hear from you about why stable funding for the Indian Health Service (IHS) should be on the must-have list.

Last week: The Native American Caucus sent a bipartisan letter from nearly 30 Members of Congress to leadership to request advance appropriations for IHS in the end-of-year package.

This week: The National Indian Health Board sent an updated letter with nearly 140 groups, including Tribes, Urban Indian Organizations, and other supporters to Congress and the White House reiterating the need for stable funding for IHS this year:

  • “Each day without full funding, with only temporary or no funding from the Continuing Resolutions or government shutdowns, is a step backward for Indian health care systems. Health care service delivery, administrative functions, and other operations are significantly impeded, delayed, or disrupted during periods of Continuing Resolutions or government shutdowns to the detriment of the American Indian and Alaska Native patients.”

What can you do?

It’s time to take action: We urge you to contact your Member of Congress and request that they support including advance appropriations for IHS in the FY 2023 final spending package. You can use the text below as a template to call and/or email your Members of Congress.

  • Step 1: Find your Representative here and your Senators here.
  • Step 2: Use the call script and copy the email below.
  • Step 3: Call and email. Use the call script to call your Members of Congress. Next, copy and paste the email into the form on their contact page and send.
Call Script

“(Introduce yourself). It is time that the federal government protect healthcare funding for Native Americans as it does for other health programs. Please let leadership know that advance appropriations for the Indian Health Service must be in the final spending package. Not another Native life should be lost due to budget uncertainty. Can I count on your support?”

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.

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!

Please do what’s right for American Indians and Alaska Natives by ensuring that advance appropriations for IHS can finally be made a reality this year.

Thank you for your leadership.

Sincerely,
[contact information]

Do more! Visit our social media toolkit and

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

Why does the Indian Health Service need advance appropriations?

The Indian health system, including IHS, Tribal facilities, and urban Indian organizations (UIOs), is the only major federal healthcare provider funded through annual appropriations.

  • Short-term budgets cause delayed funding to Indian Health Care Providers that can impact service delivery for patients and families. This is unacceptable.
  • If IHS were to receive advance appropriations, it would ensure continuity of care for American Indians and Alaska Natives.

Over 50% of Native Veterans use the Indian health system for care. VA health funding is protected, but Congress doesn’t protect Native health care. This is unacceptable for our heroes.

Native communities have experienced deaths due to government shutdowns in the past. Five deaths during the last government shutdown is too many.

By the numbers: According to a recent CDC study, Native Americans experienced the biggest drop in life expectancy of any population in the past two years— decreasing by 6.6 years between 2019-2021!

The bottom line: The lives of Native people should not be subject to politics. We need this to protect Native people and preserve access to health care.

Resources

Native Lives Can’t Wait

Photo of Chairman W. Ron Allen

During the White House Tribal Nations Summit, Native leaders gathered to call on Congress to take action now:

Congressional leaders support stabilizing health care delivery for the Indian Health Service.

Senator Dianne Feinstein Tweet

The White House supports advance appropriations. Secretary Becerra said:

It’s an imperative to be able to provide health care regardless of what the political climate is in Washington, DC. So our job is to continue to push the President’s agenda of having mandatory funding for Indian country. And if we can’t get Congress to go all the way to mandatory funding, at least give us advanced appropriations. So that this way Indian country has a way to foresee what’s coming for the next year.

Let’s keep going and make advance appropriations for the Indian Health Service a reality this year.

Bipartisan Group of over Two Dozen Congressional Leaders Request Stable Funding for the Indian Health Service

On December 6, 2022, the House Native American Caucus sent a letter with 29 signatures from Members of Congress to the House Committee on Appropriations Chair Rosa DeLauro and Ranking Member Kay Granger on including advanced appropriations for IHS in the final Fiscal Year (FY) 2023 Appropriations bill. With the ultimate goal of mandatory funding, the letter urges the Biden Administration, the Indian Health Service (IHS), authorizing committees, and tribal nations to collaborate and work towards authorizing the shift away from discretionary funding.

The letter emphasizes that “all other federal government healthcare providers—Medicare, Medicaid, Children’s Health Insurance Program, TRICARE, and Veterans Health Administration—are all either under mandatory funding or receive advanced appropriations. IHS is the only major federal healthcare program that does not receive either and is up for annual appropriations,” and “[a]dvanced appropriations for FY24 will enable IHS to continue to provide health services without potential interruption, guaranteeing access to the necessary care for 2.6 million Native Americans and Alaska Natives.”

The outlined priorities include advance appropriations for FY24 to address the disruptions and chronic underfunding of IHS. Appropriate funding can help to avoid the current challenges including staffing shortages, limited equipment availability, and extended wait times. In addition, each Continuing Resolution (CR) requires hundreds of tribal and urban Indian organization (UIO) contracts to adjust for funding, affecting financial stability. Advanced appropriations give Indian health programs the ability to manage budgets, coordinate care, and improve health quality outcomes.

This letter sends a powerful and straightforward message to Chair DeLauro and Ranking Member Granger that in order to fulfill the federal government’s trust responsibility to all AI/ANs to provide safe and quality healthcare, funding for Indian health must be secure.

NCUIH is grateful for the support of the following Representatives:

  1. Rep. Tom Cole, Co-chair, Congressional Native American Caucus
  2. Rep. Sharice Davids, Co-chair, Congressional Native American Caucus
  3. Rep. Markwayne Mullin, Vice Chair, Congressional Native American Caucus
  4. Rep. Doug LaMalfa, Vice Chair, Congressional Native American Caucus
  5. Rep. Raúl M. Grijalva, Vice Chair, Congressional Native American Caucus
  6. Rep. Frank Pallone Jr., Vice Chair, Congressional Native American Caucus
  7. Rep. Betty McCollum, Vice Chair, Congressional Native American Caucus
  8. Rep. Mary Peltola
  9. Rep. Earl Blumenauer
  10. Rep. Darren Soto
  11. Rep. Adam Smith
  12. Rep. Tom O’Halleran
  13. Rep. Joe Neguse
  14. Rep. Daniel T. Kildee
  15. Rep. Dusty Johnson
  16. Rep. Jared Huffman
  17. Rep. Kurt Schrader
  18. Rep.  Gwen Moore
  19. Rep. Doris Matsui
  20. Rep. Peter DeFazio
  21. Rep. Raul Ruiz
  22. Rep. Zoe Lofgren
  23. Del. Eleanor Holmes Norton
  24. Rep. Melanie Stansbury
  25. Rep. Shontel Brown
  26. Rep. Teresa Leger Fernández
  27. Rep. Tony Cárdenas
  28. Rep. Ruben Gallego
  29. Rep. Liz Cheney

Full Letter Text

Dear Chairwoman DeLauro and Ranking Member Granger,

In the Fiscal Year 2023 (FY23) President’s Budget, the President requested that the funding for the Indian Health Service (IHS) be shifted from discretionary to mandatory funding. This will ensure funding is secured for IHS and the millions of Native Americans and Alaska Natives it serves, regardless of a government shutdown and delayed appropriations. All other federal government healthcare providers—Medicare, Medicaid, Children’s Health Insurance Program, TRICARE, and Veterans Health Administration—are all either under mandatory funding or receive advanced appropriations. IHS is the only major federal healthcare program that does not receive either and is up for annual appropriations.

As members of the Congressional Native American Caucus, we encourage the Biden Administration, IHS, authorizing committees, and tribal nations to collaborate and work towards authorizing this shift to mandatory funding. While this process is underway, advanced appropriations for IHS should be included in the final FY23 Appropriations bill. The advanced appropriations for FY24 will enable IHS to continue to provide health services without potential interruption, guaranteeing access to the necessary care for 2.6 million Native Americans and Alaska Natives.

IHS has been chronically underfunded since its creation in 1955. According to a Government Accountability Office (GAO) Report, in 2017 per capita spending for IHS was $4,078 compared to $13,185 for Medicare. Due to these insufficient funds, IHS regularly experiences staffing shortages, limited equipment availability, extended wait times, and several other problems. Every time Congress passes a Continuing Resolution (CR), IHS must modify hundreds of tribal contracts to adjust for the available funding. This also takes an extensive toll on a tribe’s financial stability as higher interest on loans can occur when there is uncertainty of federal funding, leading to a downgrade in credit rating.

Advanced appropriations would allow Indian health programs to manage budgets, coordinate care, and improve health quality outcomes for Native Americans and Alaska Natives effectively and efficiently. This population suffers disproportionately from a variety of health afflictions including diabetes, heart disease, tuberculosis, and cancer. This change in the appropriations schedule will help the federal government meet its trust obligation to tribal governments and bring parity to federal health care systems. Health care services in particular require consistent and reliable funding to be effective.

Background on Mandatory Funding and Advance Appropriations for the Indian Health Service

The Indian health system, including IHS, Tribal facilities, and UIOs, is the only major federal provider of health care that is funded through annual appropriations. If IHS were to receive mandatory funding or, at the least, advance appropriations, it would not be subject to the harmful effects of government shutdowns and CRs as its funding for the next year would already be in place. This is needed as lapses in federal funding put lives at risk. Without funding certainty during government shutdowns can cause UIOs to reduce services, close their doors, or force them to leave their patients without adequate care.  During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS has been a major priority for Indian Country and NCUIH has taken part in extensive advocacy to ensure the continuation and delivery of health services to all Native people regardless of where they live.

There has also been strong long-standing support from Congress on this issue and legislation on this effort has been introduced in 11 bills since 2013. Currently, 107 current Members of Congress have expressed support for advance appropriations for the Indian Health Service since the first bill was introduced by the late Representative Don Young (R-AK-At Large; H.R. 3229) and Senator Lisa Murkowski (R-AK; S. 1570). Congress has sent letters in the past advocating on this issue:

  • January 12, 2022 – Native American Caucus sent letters to the House Appropriations Committee Chair DeLauro and Ranking Member Granger requesting that advance appropriations for IHS for FY 2023 be included in the final FY 2022 appropriations bill on January 12, 2022.
  • April 25, 2022 – Bipartisan group of 28 Representatives requestedup to $949.9 million for urban Indian health in FY 2023 and advance appropriations for IHS until such time that authorizers move IHS to mandatory spending, and 12 Senators sent a letter with the same requests.
  • June 3, 2022 – Native American Caucus sent another letterencouraging the Committee to work towards shifting IHS from discretionary to mandatory funding and requesting that, while this shift is underway, the Committee include advanced appropriations for IHS in the final FY 2023 Appropriations bill.

Resources on Advance Appropriations for IHS:

Next Steps

Congress has until December 16, 2022, to pass a longer-term spending package for FY 2023. In the meantime, NCUIH will continue to advocate for advance appropriations in the final FY 2023 omnibus.

NCUIH Joins NIHB and over 130 Tribal Nations and Other Organizations in Urgent Push for Stable Funding for the Indian Health Service

As Native American Heritage Month ended, advocates for Native communities joined together during the Tribal Nations Summit in Washington, DC to call for Congress and the White House to enact Advance Appropriations for Indian health now.

On December 12, 2022, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB) and over 130 groups, including Urban Indian Organizations (UIOs), Tribal Nations, and friends of Indian health in sending letters to the President and Congressional leadership while negotiations on Fiscal Year (FY) 2023 spending are currently underway. The letters request support for the House-passed funding of $8.121 billion for the Indian Health Service (IHS) for FY 2023 and advance appropriations for IHS for FY 2024. The urgency is being felt among advocates as the government is currently funded under a Continuing Resolution through December 16. During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS in the final FY 2023 omnibus has been a major priority for Indian Country to ensure the continuation and delivery of health services to all Native people regardless of where they live.  There is bipartisan support for ensuring advance appropriations and ending budget delays for the Indian Health Service.

This week, allies joined in support of a Day of Action on November 30, 2022 on the last day of Native American Heritage Month and the first day of the White House Tribal Nations Summit.

Photo of Chairman W. Ron Allen

Native Leaders Call on Congress to Act Now on Advance Appropriations

A Bipartisan Tradition: Supporting Stability for the Indian Health Service Unites a Divided Congress

Currently, 107 current Members of Congress have expressed support for advance appropriations for the Indian Health Service since the first bill was introduced by the late Representative Don Young (R-AK-At Large; H.R. 3229) and Senator Lisa Murkowski (R-AK; S. 1570) in 2013. Closing today, House Native American Caucus Co-Chairs Sharice Davids (D-KS-03) and Tom Cole (R-OK-04) are leading the third bipartisan letter of the year to the House Appropriations Committee calling for advanced appropriations for IHS to be included in the final FY23 Appropriations bill. Members of Congress also joined the Day of Action conversation by expressing their direct support for protecting IHS funding. For example:

  • Longstanding sponsor of the Indian Health Service advance appropriations, Rep. Betty McCollum (D-MN-04) called on her colleagues to vote in support of advance appropriations and stated that “Vital health care services should NOT be interrupted if there’s a government shutdown.”
  • Former Chair of the Senate Committee on Indian Affairs and current Committee Member, Senator John Tester (D-MT) stated, “Our Native communities deserve a stable health care system—yet the Indian Health Service is the only major federal provider without stable funding. I stand with advocates across Indian Country today in pushing for advance appropriations for the IHS.
  • Champion of the Honoring Promises to Native Nations proposal, Senator Elizabeth Warren (D-MA) said, “IHS is the only major federal provider of health care that faces budget uncertainty. It’s time for Congress to guarantee predictable funding and end this inequity.”
  • Melanie Stansbury (D-NM-01), member of the House Natural Resources Committee, stated that “When budget negotiations falter, Indigenous lives are at stake… I stand with Indigenous communities in support of advance appropriations for the Indian Health Service.”.
  • Staunch advocate for IHS on the Energy and Commerce Committee, Rep. Raul Ruiz (D-CA-36) stated that “Lack of funding shouldn’t be an impediment for our Tribes to receive the lifesaving services they need and deserve.
Full List of Letter Supporters

The full list of supporting Tribal Nations and organizations is as follows:

Tribal Nations:
  • Absentee Shawnee Tribe of Oklahoma
  • Caddo Nation
  • Chickasaw Nation
  • Citizen Potawatomi Nation
  • Cloverdale Rancheria of Pomo Indians of California
  • Confederated Tribes of the Colville Reservation
  • Cowlitz Tribe
  • Fond du Lac Band of Lake Superior Chippewa
  • Jamestown S’Klallam Tribe
  • Jamul Indian Village of California
  • Keweenaw Bay Indian Community
  • La Posta Band of Mission Indians
  • Lummi Indian Business Council
  • Manchester Point Arena Band of Pomo Indians
  • Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians (Gun Lake Tribe)
  • Mississippi Band of Choctaw Indians
  • Nez Perce Tribe
  • Oneida Nation
  • Pechanga Band of Indians
  • Peoria Tribe of Indians of Oklahoma
  • Poarch Creek Indians
  • Pueblo of Tesuque
  • Pyramid Lake Paiute Tribe
  • Rappahannock Tribe
  • Resighini Rancheria
  • Saint Regis Mohawk Tribe
  • San Carlos Apache Tribe
  • Sault Ste. Marie Tribe of Chippewa Indians
  • Skokomish Tribe
  • Sokaogon Chippewa Community
  • Standing Rock Sioux Tribe
  • Swinomish Indian Tribal Community
  • Tohono O’odham Nation
  • Tsalagiyi Nvdagi Tribe
  • Tunica-Biloxi Tribe of Louisiana
  • Upper Mattaponi Indian Tribe
  • Walker River Paiute Tribe
  • Wampanoag Tribe of Gay Head (Aquinnah)
  • Ysleta del Sur Pueblo
Organizations:
  • ACA Consumer Advocacy
  • AI/AN Health Partners
  • Alaska Native Health Board
  • Alaska Native Tribal Health Consortium
  • Albuquerque Area Indian Health Board, Inc.
  • American Academy of Dermatology Association
  • American Academy of Pediatrics
  • American Indian Health & Services
  • American Indian Health Commission for Washington State
  • American Indian Health Service of Chicago
  • Association on American Indian Affairs
  • Bakersfield American Indian Health Project, Inc.
  • Bristol Bay Area Health Corporation
  • California Consortium for Urban Indian Health
  • California Rural Indian Health Board
  • Canoncito Band of Navajos Health Center
  • Caring Ambassadors Program
  • Choctaw Health Center
  • Coalition of Large Tribes
  • Colorado Consumer Health Initiative
  • Consolidated Tribal Health Project, Inc.
  • Cook Inlet Tribal Council, Inc.
  • Copper River Native Association
  • Council of Athabascan Tribal Governments
  • Every Texan
  • Fallon Tribal Health Center
  • Families USA
  • Family Voices
  • First Focus on Children
  • Fresno American Indian Health Project
  • Great Lakes Area Tribal Health Board
  • Great Plains Tribal Leaders’ Health Board
  • Health Care Voices
  • Hepatitis C Mentor & Support Group, Inc.
  • Hunter Health
  • Indian Health Care Resource Center of Tulsa
  • Indian Health Center of Santa Clara Valley
  • Indigenous Pact
  • Inter Tribal Association of Arizona
  • International Association for Indigenous Aging
  • International Association of Forensic Nurses
  • Justice in Aging
  • Kansas City Indian Center
  • Kids Forward
  • Maniilaq Association
  • Metro New York Health Care for All
  • Michigan League for Public Policy
  • National Association of Pediatric Nurse Practitioners
  • National Council of Urban Indian Health
  • National Indian Health Board
  • National Indigenous Women’s Resource Center
  • National League for Nursing
  • National Native American Boarding School Healing Coalition
  • National Partnership for Women & Families
  • Native American Connections
  • Native American LifeLines, Inc.
  • Native American Rehabilitation Association of the Northwest, Inc.
  • Native Americans for Community Action, Inc.
  • NATIVE Project – Urban Indian Health Program – Spokane, WA
  • Nevada Coalition to End Domestic and Sexual Violence
  • Nisqually Tribal Health & Wellness Center
  • Northwest Harvest
  • Northwest Portland Area Indian Health Board
  • Oklahoma City Indian Clinic
  • Oklahoma Policy Institute
  • Partners In Health
  • R2H Action [Right to Health]
  • Riverside-San Bernardino County Indian Health, Inc.
  • Rocky Mountain Tribal Leaders Council
  • San Francisco AIDS Foundation
  • Sault Tribe Health Division
  • Seattle Indian Health Board
  • Self-Governance Communication & Education Tribal Consortium
  • SF Hep B Free – Bay Area
  • South Dakota Urban Indian Health
  • Southcentral Foundation
  • Southeast Alaska Regional Health Consortium
  • Southern Indian Health Council, Inc.
  • Southern Plains Tribal Health Board
  • Texas Native Health
  • Treatment Action Group
  • Tuba City Regional Health Care Corporation
  • United American Indian Involvement, Inc.
  • United South and Eastern Tribes Sovereignty Protection Fund
  • Universal Health Care Foundation of Connecticut
  • University of California San Francisco School of Medicine HEAL Initiative
  • Urban Inter-Tribal Center of Texas – Urban Indian Health Program – Dallas, TX
  • USAging
  • Wiconi Wakan Health and Healing Center
  • Work for Consolidated Tribal Health Project
Friends of Indian Health:
  • Angela Alvary
  • Ken Artis (Ho-Chunk Nation), Artis Law Office
  • Lana Fox
  • Miranda Carman, LCSW
  • Patricia Powers
  • Yana Blaise
Next Steps

NCUIH continues to advocate for the inclusion of advance appropriations for IHS in the final FY 2023 appropriations package. NCUIH will also provide updates on the status of advance appropriations in Congress during final negotiations.

President Announces Interagency Initiative to Address Homelessness for Urban Native Veterans

VA, HHS, HUD, through the White House Committee on Native American Affairs, to increase access to care and services for Native veterans experiencing or at risk of homelessness in urban areas.

Last week, President Biden convened the White House Tribal Nations Summit where he released the Tribal Nations Summit Progress Report, which outlined a new initiative aimed to assist Native veterans experiencing or at risk of homelessness. During the White House Tribal Nations Summit on December 1, 2022, the Department of Veterans Affairs (VA) Secretary McDonough announced that the VA, in partnership with the Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and the White House Committee on Native American Affairs are launching an interagency initiative to increase access to care and services for American Indian and Alaska Native (AI/AN) veterans experiencing or at risk of homeless in urban areas. According to Secretary McDonough, “the initiative will involve enhanced partnerships with 41 urban Indian organizations and will focus on intake and referral services to ensure that Native veterans are aware of and have access to resources already set aside for them.”

“I am encouraged by the VA’s commitment to improving the health and well-being of Native veterans, including those of us living in urban areas. Natives serve in the military at a higher rate than any other population in the U.S., but we experience some of the largest health disparities when we complete our service. As we all know, housing is a key social determinant of health, and homelessness in our community is a contributing factor to the health inequities Native veterans face. I look forward to being involved in the partnership between urban Indian organizations and the VA, HHS, HUD, and White House Council on Native American Affairs to bring housing resources to urban Native veterans.”– Sonya Tetnowski (Makah), CEO, Indian Health Center of Santa Clara Valley and NCUIH President.

Background

Native Veteran Disparities 

Native veterans have served in the United States military in every armed conflict in the Nation’s history and have traditionally served at a higher rate than any other population in the United States. Unfortunately, Native veterans suffer significant disparities when they transition to civilian life. For example, Native veterans are more likely to be uninsured and have a service-connected disability than other veterans. Native veterans suffer these disparities no matter where they live. Native veterans living in urban areas experience the same poor physical and mental health outcomes as Native veterans in rural areas. In addition, urban Native veterans generally have lower incomes, higher unemployment, lower education attainment, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native urban veterans.

This initiative is critical given that the National Council of Urban Indian Health (NCUIH) estimates that there are about 8 Native veterans experiencing homelessness per 1000 veterans, compared to about 1.5 white veterans per 1000 veterans. Urban Native veterans are greatly impacted by this, as NCUIH estimates that 86.2% of the veteran population identifying as Native lives in urban areas.  Homelessness is a key Social Determinant of Health (SDOH) and a lack of stable housing can lead to an increased risk of premature death, preterm delivery, exposure to disease vectors like vermin, and other negative health impacts.  Without consistent access to stable housing for all of our Native veterans, who have answered the call to make the ultimate sacrifice on behalf of this Nation, they will remain at risk of the health disparities associated with unstable housing.

Urban Indian Organizations Provide Critical Housing Support 

UIOs are essential partners in serving AI/AN veterans and are vital to this initiative to improve care and access to services for AI/AN veterans because of their deep ties to the AI/AN community in urban areas. UIOs currently serve seven of the ten urban areas with the largest AI/AN veteran populations, including the following areas: Phoenix, Arizona; Los Angeles, California; Seattle, Washington; Dallas, Texas; Oklahoma City, Oklahoma; New York City, New York; and Chicago, Illinois.  Due to the cultural competency of the health care available at UIOs, many Native veterans prefer to receive their health care from a UIO provider, as well as at IHS and Tribal facilities, over a VHA facility.

UIOs are uniquely positioned to assist agencies, such as the VA, HHS, and HUD, in improving housing access for AI/AN people. Some UIOs already provide housing services and all UIOs provide numerous other social and community services to AI/ANs living in urban areas. As such, the partnership with UIOs announced in this initiative has the potential to improve the quality of care and well-being to Native veterans in urban areas, but it is also consistent with the United States’ trust responsibility to provide services and resources to improve the health of all AI/ANs.

Sonya Tetnowski, Chair of Veterans Health Administration Subcommittee within the VA Advisory Committee on Tribal and Indian Affairs Committee, Army veteran, NCUIH President, and CEO of the Indian Health Center for Santa Clara Valley, highlighted the importance of looking at the whole person and making sure that their needs are being met during a Committee meeting in January. She also brought forth potential subcommittees, including unhoused urban Veterans, Native Healer utilization, and Behavioral Health and Substance Use. On August 17, 2022, the Committee held a meeting where Ms. Tetnowski presented five priority areas, including homelessness and housing as a priority.

NCUIH and the VA 

NCUIH continues to advocate on behalf of AI/AN veterans living in urban areas and to strengthen its partnership with VA. Thanks to NCUIH’s work with the VA, UIOs are now eligible to enter the VA IHS/THP/UIO Reimbursement Agreements Program, which provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible AI/AN Veterans. NCUIH also played a critical role in getting the legislation that established the VA Advisory Committee on Tribal and Indian Affairs passed in 2020 and nominated Ms. Tetnowski to be a representative on the Committee.

NCUIH has highlighted in several written comments to the VA and in meetings with agency representatives, the need for the VA to address and provide services to Native veterans living in urban areas. VA data currently indicates that Native veterans use VA benefits or services at a lower percentage than other veterans. To address these disparities, NCUIH has provided the VA with several recommendations and administrative guidance on how to improve Native veteran health through collaboration with the VA. In the last year alone, NCUIH has raised various issues such as the lack of VA services provided to Native veterans who reside in urban areas as well as the lack of culturally competent VA health care providers in these areas. In July, NCUIH wrote to comments to the VA urging the agency to improve the medical workforce at UIOs through the Pilot Program on Graduate Medical Education and Residency (PPGMER). Moreover, NCUIH recently provided comments and recommendations for the VHA and IHS in collaboration to improve their outreach and services to urban Native veterans.

In addition to working with the VA, NCUIH submitted comments to HUD, encouraging the agency to incorporate urban Natives in its FY22-26 Strategic Plan and focus areas. HUD provides housing resources and funding for Tribes, but these resources are very limited when it comes to urban AI/ANs, or not applicable at all. These efforts have emphasized the critical importance of working with UIOs to reach and serve the significant portion of Native veterans living in urban areas.

Senator Warren and Representative Kilmer Introduce NCUIH-Endorsed Bill to Honor Promises to Native People with Key Provisions for Urban Indian Health

On December 5, 2022, Senator Elizabeth Warren (D-MA) and Representative Derek Kilmer (D-WA-6) introduced the Honoring Promises to Native Nations Act, which will address the underfunding and barriers to sovereignty in Indian Country acknowledged in the 2018 U.S. Commission on Civil Rights report, Broken Promises: Continuing Federal Funding Shortfall for Native Americans. The legislation reaffirms the federal government’s trust obligation to all American Indians and Alaska Natives (AI/ANs) to strengthen federal programs and support Native Communities. This legislation guarantees mandatory, full, and inflation-adjusted funding that can support healthcare, education, housing, and economic development and is cosponsored by national Indian organizations such as the National Council of Urban Indian Health (NCUIH), the National Congress of American Indians, and the National Indian Health Board.

NCUIH worked closely with Senator Warren’s office on this landmark policy platform, which includes permanent 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and modifying an existing policy to allow the Secretary of the Department of Health and Human Services (HHS) to better communicate on issues affecting urban Indian health. Additionally, the legislation includes mandatory-adjusted funding for the Indian Health Service (IHS), advance appropriations for IHS, increased long-term funding for Special Diabetes Programs for Indians (SDPI) to $300 million through fiscal year (FY) 2032 (currently expiring in FY 2023 and only funded at $150 million annually), and exempting Indian programs from sequestration.

“For generations, the U.S. government has clearly failed to fulfill its commitments to Tribal Nations. This bill is sweeping in ambition to make good on those commitments and empower Native communities, and it provides a much-needed legislative blueprint to deliver significant, long-term funding for the advancement of Native Americans. I won’t stop fighting to ensure the U.S. government honors its promises,” said Senator Warren. 

 “Congress and the federal government have a moral and a legal obligation to fulfill the promises made to Indian Country. That’s why I’m proud to introduce this legislation with Senator Warren to help reverse the decades-long pattern of systemic funding shortfalls to Native communities and to strengthen federal programs that support Indian Country. Congress should move swiftly to get this legislation enacted. It is long overdue.” said Representative Kilmer. 

 “The health of our people has suffered due to the failure of the government to uphold the trust responsibility of providing health care to all American Indians and Alaska Natives. It is time that we address the needs of Indian Country and enact the recommendations included in the 2018 Broken Promises report, including improving health care for all Native people. The National Council of Urban Indian Health is grateful for the inclusion of Urban Indians in this legislation, especially regarding permanent 100% FMAP for urban Indian organizations and Urban Confer within HHS, both of which have been top priorities for NCUIH. We fully support this bill and believe that this Act is fundamental in honoring the federal government’s trust responsibility to American Indian and Alaska Natives,”Francys Crevier (Algonquin), CEO, NCUIH.

 “On behalf of the nearly 1/4 UIOs in California, CCUIH endorses the Honoring Promises to Native Nations Act because it will increase health access for American Indians no matter where they live.  California is home to the largest population of American Indians, with more than 90% living in an urban area.  Full, mandatory, inflation-adjusted funding for the Indian Health Service; funding for the Special Diabetes Programs for Native Americans; permanent FMAP for Urban Indian Health Programs; and Medicaid coverage of any services provided by Indian health care providers will offer critical funding necessary to address the continued disparities in health experienced by American Indians,”Virginia Hedrick (Yurok), Executive Director, California Consortium for Urban Indian Health, Inc.

 “The American Indian Health Service of Chicago, Inc. is pleased to endorse the Honoring Promises to Native Nations Act, as it will enable the 70% of American Indians and Alaska Natives who live in Urban Areas to continue to receive the same level of care that is received by other federally funded health programs, while slowly moving toward true health equity with the rest of the United States. With hope that Urban Programs will be able to receive an increase in the funding to be able to offer additional services (such as dental, podiatry, imaging, and women’s wellness) to the American Indian and Alaska Native Chicago based population. AIHSC also appreciates the efforts to increase the Special Diabetes Program for Indians, as our percentages of AI/AN who are diagnosed with diabetes increase,” RoxAnne M LaVallie-Unabia (Turtle Mountain Band of Chippewa Indians), Executive Director, American Indian Health Service of Chicago.

 “South Dakota Urban Indian Health enthusiastically supports the Honoring Promises to Native Nations Act. This bill secures funding for essential health services and through the inclusion of Medicaid reimbursements for substance use disorder facilities, recognizes the urgency of addiction for our relatives. For generations, Native Americans have persevered through forced assimilation, forced removal from our ancestral lands, and broken promises from the United States government. Despite these challenges, we remain a thriving group of sovereign nations and peoples across the geographic United States. This bill is a stride toward health equity for the more than 70% of Native Americans who live in urban areas of the United States.”Michaela Seiber (Sisseton-Wahpeton Dakota), CEO, South Dakota Urban Indian Health.

 “Native Health endorses the Honoring Promises to Native Nations Act because it will provide resources to fulfill the Federal Government’s obligation to provide health care to AI/ANs. The bill supports urban Indian organizations through 100% FMAP and SDPI reauthorization. These measures are especially needed by the underserved AI/AN urban community. In the current environment, UIOs are overwhelmed by the rising demand and the rising costs of providing health care,” – Walter Murillo (Choctaw Nation of Oklahoma), CEO, Native Health.

 “The Honoring Promises to Native Nations Act is a major step forward in recognizing the trust and treaty obligations to Tribes and American Indian and Alaska Native peoples,” – Jacqueline Mercer, CEO, Native American Rehabilitation Association of the Northwest (NARA).

 “Hunter Health endorses the Honoring Promises to Native Nations Act because it will increase access to quality healthcare services and allows Urban Indian Organizations to work with their state to expand services for Native American people living in their community,” – Rachel Mayberry, Chief Advancement Officer, Hunter Health.

 “The Indian Health Center of Santa Clara Valley is pleased to endorse Senator Warren’s Honoring Broken Promises Act. This bill addresses priorities for urban Indian organizations such as mandatory funding, 100% FMAP, increased SDPI funding, and urban confer. This bill contributes to health equity for American Indians and Alaska Natives and moves forward with the federal government’s trust and treaty responsibility by improving AI/AN health services,” – Sonya Tetnowski (Makah), CEO, Indian Health Center of Santa Clara Valley.

 “Denver Indian Health and Family Services endorses the Honoring Promises to Native Nations Act because it will allow all Urban Indian Organizations (UIOs) to leverage their services and sustain their funding despite many healthcare challenges. (i.e., the pandemic, the opioid crisis, suicide prevention, etc.). It is time the federal government met its trust and treaty obligations to Native peoples, particularly regarding federal spending. Failing to fund Indian Health Service (IHS) fully and UIOs fails to fulfill the federal government’s trust responsibilities. As recipients of less than 1% of the Indian Health Service budget, inadequate funding requires UIOs to depend on every dollar of federal funding and find creative ways to stretch limited resources. The Act will cover a wide range of issues that impact Indian Country; specifically, urban confer for HHS and the VA; 100% FMAP for UIOs; and Special Diabetes for Indians, reauthorized at $300 million for ten years,” – Adrianne Maddux (Hopi Tribe), Executive Director, Denver Indian Health and Family Services.

 “The Oklahoma City Indian Clinic (OKCIC) endorses the Honoring Promises to Native Nations Act because it will provide promised and necessary funding for Indian Health Care services.  The OKCIC is the largest Urban Indian Health Care Center in the United States, serving 22,000 patients from over 200 Tribes. Many of our patients are chronically ill and require high levels of expensive medical care.  To provide that care it is very important that Title II of the Honoring Promises to Native Nations Act, specifically a full, mandatory and inflation-adjusted funding for the Indian Health Service and permanent adequate funding for the Special Diabetes Program for Indians is not only necessary but vital to maintaining the good health of our people,” – Robyn Sunday-Allen (Cherokee), CEO, Oklahoma City Indian Clinic.

Bill Highlights for Urban Indian Organizations

Mandatory Funding and Advance Appropriations for the Indian Health Service

The Indian health system, including IHS, Tribal facilities, and UIOs, is the only major federal provider of health care that is funded through annual appropriations. If IHS were to receive mandatory funding or, at the least, advance appropriations, it would not be subject to the harmful effects of government shutdowns and continuing resolutions (CRs) as its funding for the next year would already be in place. This is needed as lapses in federal funding put lives at risk. Without funding certainty during government shutdowns can cause UIOs to reduce services, close their doors, or force them to leave their patients without adequate care.  During the last government shutdown, UIOs reported at least 5 patient deaths and significant disruptions in patient services. Securing stable funding for IHS has been a major priority for Indian Country and NCUIH has taken part in extensive advocacy to ensure the continuation and delivery of health services to all Native people regardless of where they live.

This bill authorizes $50,138,679,000 in mandatory appropriations for FY 2023, $51,416,373,000 for FY 2024, and for FY 2025 and each fiscal year thereafter, “an amount equal to the sum of the amount appropriated for the previous fiscal year, as adjusted annually to reflect the change in the medical care component of the consumer price index for all urban consumers (U.S. city average); and, as applicable, 1.8 percent of the amount appropriated for the previous fiscal year.” The bill also provides advance appropriations for IHS.

Special Diabetes Programs for Indians

The SDPI Demonstration Project includes research-based interventions for diabetes prevention and cardiovascular disease (CVD) risk reduction into AI/AN community-based programs and health care settings. The program has demonstrated success with a 50% reduction in diabetic eye disease rates, drops in diabetic kidney failure, and a 50% decline in End Stage Renal Disease. Many UIOs receive SDPI funding and the program has directly enabled UIOs to provide critical services to their AI/AN patients, in turn significantly reducing the incidence of diabetes and diabetes-related illnesses among urban Indian communities. These successes are impactful, as AI/ANs have the highest diabetes prevalence rates of all racial and ethnic groups in the United States, with AI/AN adults almost three times more likely than non-Hispanic white adults to be diagnosed with diabetes. According to the Centers for Disease Control and Prevention, 13.7% of adults in urban Native communities are diagnosed with diabetes. SDPI is a critical program to address the high rates of diabetes among AI/ANs and requires secure funding to continue its success. NCUIH has long advocated for SPDI to be fully funded. On May 16, 2022, NCUIH submitted comments and recommendations to IHS emphasizing the importance of SDPI in reducing health disparities related to diabetes for AI/AN populations. These comments included increasing SDPI funding with built-in automatic annual medical inflationary increases and that IHS ensures the SDPI remains inclusive of UIOs.

This legislation will reauthorize SDPI at $300,000,000 for each fiscal year beginning in 2023 through 2032.

Permanent 100% Federal Medical Assistance Percentage (FMAP)

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent 100% FMAP for UIOs will further the government’s trust responsibility to AI/ANs by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA) which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

This bill amends the Social Security Act by including UIOs as eligible entities to receive permanent 100% FMAP.

 Urban Confer with HHS and UIOs

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 addressing the care needs of a majority of AI/ANs. An urban confer policy that includes all HHS agencies, including the Centers for Medicare & Medicaid Services (CMS), ensures 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. NCUIH has long advocated for facilitating confer between numerous federal branches within HHS and UIO stakeholders. 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.

This bill would require the Secretary of HHS, to the maximum extent practicable, to confer with UIOs in carrying out the health services of the Department.

 Office of Management and Budget Office of Native Nations

The bill establishes an Office of Native Nations within the Office of Management (OMB), which coordinates with the rest of OMB and the Executive branch on matters of funding for federal programs and policy affecting AI/ANs and Native Hawaiians. The Administrator, a career position, of the office is responsible for matters such as compiling data on all federal funding for federal programs affecting AI/ANs and Native Hawaiians; ensuring that the budget requests of IHS and the Bureau of Indian Affairs indicate how much funding is needed for programs affecting AI/ANs and Native Hawaiians to be fully funded and how far the federal government is from achieving that full funding; and preparing a crosscutting document each fiscal year containing detailed information, based on data from all federal agencies, on the amount of federal funding that is reaching Indian Tribes, tribal organizations, Native Hawaiian organizations, and UIOs. The bill directs the Administrator to consult with Indian Tribes, collaborate with Native Hawaiian organizations, and confer with UIOs annually to ascertain how the crosscutting document can be modified to make it more useful to Indian Tribes, Native Hawaiian organizations, and UIOs.

On September 12, 2022, after recommendations from NCUIH and Tribal leaders, the Biden administration created a position of a Tribal Policy Advisor within OMB to communicate the needs of Indian Country and AI/ANs. This position was an important first step in ensuring that Native voices are heard during the budget process, and we are grateful that this bill works to further consider the needs of Native programs in federal funding.

Next Steps

Senator Warren and Congressman Kilmer invite comments and feedback on how to refine and improve the legislation in the next Congress. Written input can be submitted at HonoringPromises@warren.senate.gov.

Background

Broken Promises

On December 20, 2018, the Broken Promises report was released and addressed areas where the federal government has failed to fulfill its trust responsibility, including criminal justice and public safety, health care, education, housing, and economic development. Specifically, the report requests advance appropriations for the IHS and funding to implement the Indian Health Care Improvement Act, including job training programs to address chronic shortages of health professionals in Indian Country and a mental health technician training program to address the suicide crisis in Indian Country. The report also recommends direct, long-term funding to Tribes, analogous to the mandatory funding Congress provides to support Medicare, Social Security, and Medicaid, avoiding pass-through of funds via states.

The proposal for this bill was first introduced in August 2019 by Congresswoman Deb Haaland (D- N.M.) and Senator Warren. Lawmakers then took feedback from tribal governments and citizens, tribal organizations, UIOs, experts, and other stakeholders which informed the development of this current legislation.

Partnership for Medicaid Advocates for Key Urban Indian Health Priority in Omnibus Request

On October 28, 2022, the Partnership for Medicaid (Partnership) sent a letter to House and Senate leadership urging that several Medicaid policy proposals be prioritized as Congress considers an end-of-year health care package. In the letter, they requested that Congress seek to include legislation that would extend 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and Native Hawaiian Health Systems for another two years. After advocacy from the National Council for Urban Indian Health (NCUIH), the American Rescue Plan Act (ARPA) authorized 8 fiscal quarters of 100% FMAP to UIOs, which is set to expire in just 3 months.

Full Letter Text

Dear Leader Schumer, Speaker Pelosi, Minority Leader McConnell, and Minority Leader McCarthy:

On behalf of the Partnership for Medicaid (Partnership), thank you for your continued commitment to the Medicaid program. Our member organizations are eager to collaborate with you to build upon efforts to sustain and strengthen Medicaid.

The Partnership – a nonpartisan, nationwide coalition made up of organizations representing clinicians, health care providers, safety net plans, and counties –appreciates initiatives from Congress throughout the COVID-19 pandemic to bolster the Medicaid program and support the health care safety net. Your continued attention has not only allowed the program to meet the needs of millions of Americans during a public health crisis but has also reinforced the importance of investing in Medicaid now to protect and sustain its promise for the future.

As the Congress considers an end-of-year health care package, the Partnership urges lawmakers to prioritize policy proposals to strengthen Medicaid and ensure its stability for underrepresented populations who rely on this critical program. Congress should seek to include legislation that would:

  • building on provisions included in the FY 2022 Continuing Resolution, create a permanent and sustainable Medicaid financing solution for Puerto Rico and other territories;
  • permanently ensure that all pregnant individuals on Medicaid and the Children’s Health Insurance Program (CHIP) keep their health coverage during the critical first year postpartum;
  • provide one year of continuous eligibility for children covered by Medicaid and CHIP;
  • appropriately fund the Medicaid program in a manner that supports states to set competitive rates necessary for garnering equitable access for Medicaid, as undervaluing Medicaid payments—and consequently, the patients Medicaid serves—perpetuates systemic barriers to health and health care and worsens health disparities;
  • invest in and improve access to Medicaid home-and community-based services (HCBS) and mental health services, including for children, while strengthening the direct care workforce;
  • provide Medicaid coverage to eligible, justice-involved individuals 30 days prior to release;
  • extend the 100 percent federal medical assistance percentage (FMAP) for Urban Indian Organizations and Native Hawaiian Health Systems for another two years;
  • make permanent Medicaid’s Money Follows the Person program and the Protection Against Spousal Impoverishment.
  • permanently fund CHIP; and
  • close the Medicaid coverage gap for Americans living in states that have yet to expand Medicaid and still lack access to health insurance

Taken together, these proposed improvements to Medicaid and CHIP represent an opportunity to stabilize and expand access to health care and long-term services and supports for millions of low-income Americans, from older adults, people with disabilities, children, pregnant and postpartum individuals, and their families, and more.

Furthermore, for Medicaid issues legislatively tied to the public health emergency, we urge Congress to proceed with caution when applying imminent, static sunsets to policies stakeholders rely upon to help mitigate COVID-19’s ongoing impact. For example, Congress should create a predictable, evidence-informed wind down of the enhanced FMAP and continuous coverage provisions included in the Families First Coronavirus Response Act that provides sufficient guardrails to protect beneficiaries while also reflecting the trajectory of the COVID-19 pandemic.

We remain grateful for your leadership and commitment to the Medicaid program and the populations it serves. If you have questions or seek any additional information, please contact Jonathan Westin at the Jewish Federations of North America, First Co-Chair of the Partnership for Medicaid at Jonathan.Westin@jewishfederations.org.

Sincerely,

America’s Essential Hospitals
American College of Obstetricians and Gynecologists
American Dental Education
Association American Network of Community Options and Resources (ANCOR)
Associations of Clinicians for the Underserved
Catholic Health Association of the United States
Children’s Hospital Association
Easterseals
Jewish Federations of North America
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of Rural Health Clinics (NARHC)
National Council for Mental Wellbeing
National Council of Urban Indian Health
National Health Care for the Homeless Council
National Rural Health Association

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

Background and NCUIH Advocacy on Medicaid

100% FMAP for UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent authorization or an extension of the 100% FMAP for UIOs provision will further the government’s trust responsibility to American Indians/Alaska Natives (AI/ANs) by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted ARPA which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

NCUIH and Partnership for Medicaid Priority: Medicaid Unwinding

After the COVID-19 Public Health Emergency (PHE), states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and Children’s Health Insurance Program (CHIP) in a process known as “unwinding.” The Partnership for Medicaid advocates for protections against the potential loss of coverage for millions of Medicaid beneficiaries at the end of the PHE. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage. This document outlines the impact of Medicaid unwinding on AI/ANs and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

Congressional Hearing Showcases Urgency of Stabilizing Indian Health Service Funding for Native Veterans

Congressional leaders emphasized the need for the VA to follow through on their promises to Native Veterans and responded to the calls for stable funding for IHS.

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

On November 30, 2022, Sonya Tetnowski, President of the National Council of Urban Indian Health (NCUIH) and CEO of the Indian Health Center of Clara Valley, Army Veteran, and citizen of the Makah Tribe testified before the Senate Committee on Veterans’ Affairs at a hearing titled “Native American Veterans: Ensuring Access to VA Health Care and Benefits.”

(Note: Ms. Tetnowski also serves as the Chair of the Health Subcommittee within the first-ever Department of Veterans Affairs (VA) Advisory Committee on Tribal and Indian Affairs, but testified in her capacity as NCUIH President and CEO of the Indian Health Center of Santa Clara Valley.)

Hearing Highlights Urgent Need for Advance Appropriations

In addition to Ms. Tetnowski, the Committee heard from the Indian Health Service (IHS) Director Roselyn Tso (Navajo), IHS Deputy Director Benjamin Smith (Navajo), Veterans Health Administration (VHA) Deputy to the Deputy Under Secretary for Health Mark Upton, VA Office of Tribal Government Relations Director Stephanie Birdwell (Cherokee Nation in Oklahoma), John Bell from Veterans Benefits Administration, Nickolaus Lewis (Lummi Nation) from the National Indian Health Board, Larry Wright, Jr. (Ponca Tribe of Nebraska) from the National Congress of American Indians (NCAI), and Leo Pollock (Blackfeet Nation) from the Blackfeet Veterans Alliance.

As negotiations for the end of the year are well underway, witnesses were united in their impassioned advocacy on behalf of Native veterans who receive health care from IHS and asking for advance appropriations for IHS. While there are many key issues facing Native veteran access to health care, it was evident how urgent stable funding for IHS is, as over half use the IHS, Tribal organization, and UIO (I/T/U) system for their care.

Ms. Tetnowski emphasized how securing advance appropriations for IHS is critical to improving the health of Native veterans since more than 50% of Native veterans use the I/T/U system for their health needs. “Gaps in federal funding put lives at risk. In fact, 5 [UIO] patients died during the last shutdown. The risk is too big and the price is too high for us to continue without advance appropriations,” said Ms. Tetnowski in her testimony, “During the last government shutdown, my clinic supported another Urban Indian program so they could remain open, this should not be happening to our patients and specifically our veterans.”

 Mr. Wright also mentioned the need for advance appropriations, stating that “Unlike the VA system, IHS continues to be subject to the harmful and disruptive effects of government shutdowns and short-term stopgap measures because it does not yet have advance appropriations. This is precisely why NCAI has long been in support of advance appropriation for IHS, and it is one step that can be taken immediately to help both Native veterans and Native communities more broadly.”

 Mr. Lewis echoed these sentiments, citing that, “In 2018, the Government Accountability Office reported how advanced appropriations have helped the VA. Our veterans are looking for that same help for IHS,” and urged the Committee to talk with the Appropriations Committee and those in leadership about including IHS advance appropriations in the final fiscal year 2023 spending bill.

 In his closing remarks, Ranking Member Jerry Moran highlighted a key takeaway that the “Indian Health Service has to be a consistent, constant provider open for business on an ongoing basis, based upon the reliance that Native Americans place in that service.”

The Indian health system is the only major federal provider of health care that is funded through annual appropriations. For example, the VHA receives most of its funding through advance appropriations, giving budget security for the agency and protecting the healthcare for veterans from government shutdowns and stopgap funding. Unfortunately, healthcare provided to Native people, including Native veterans, through IHS, Tribal facilities, or UIOs, is not similarly secure. Whenever there is a gap or disruption in IHS funding, either as a result of a shutdown or continuing resolution, Tribes and UIOs are often forced to reduce or sometimes even cease healthcare services entirely. For some Native veterans, a tribal or UIO facility is their only accessible provider of healthcare.

NCUIH thanks Chairman Tester, Ranking Member Moran, and the members of the Committee for the opportunity to testify and encourages Congress to continue to include urban Native veterans in the conversation of improving the quality of health care and services for Native veterans.

Additional Highlights

Native people have historically served in the U.S. military at a higher rate than any other population and in return for this service, the United States promises Native veterans, like all veterans, world-class benefits and services. However, Native veterans experience some of the worst health outcomes compared to other veterans and continue to experience significant barriers to accessing the benefits and services they earned through their military service.

NCUIH made the following recommendations during the hearing:

  • Improve access to care for Native veterans at their provider of choice within the Indian healthcare or veterans’ healthcare systems
  • Advance appropriations for the Indian Health Service
  • Increase outreach and technical assistance regarding the VA Reimbursement Program for UIOs
Native Veterans Utilize Indian Health Care Providers for Culturally Competent Care

Native veterans are entitled to receive healthcare through both the veterans’ healthcare system and the Indian healthcare system. Ms. Tetnowski stressed that “it is imperative that our physical, mental, and cultural needs are addressed in a culturally competent way […] we need the ability to go to a facility that understands, respects and recognizes our unique needs.” She noted that the majority of the Native veteran population lives in metropolitan areas, therefore it is important for the VHA to work with UIOs—a vital component of the I/T/U system—which provide these culturally competent services to Native veterans.

 Senator Moran raised that one challenge faced by AI/AN veterans is the distance to accessing healthcare, and sought input on what they can do to better utilize community care, telehealth, and other mechanisms to lessen that burden. Mr. Lewis responded that IHS facilities are the community care for Native veterans and “our veterans are saying they want to get their healthcare through our IHS facility instead of being forced to travel two hours to Seattle.” Ms. Tetnowski ensured that UIOs are considered in this conversation, noting that most of the urban clinics are placed in relocation sites and Native veterans in her community would rather be seen by her clinic as a Native provider. Mr. Wright agreed with her remarks and added that his Tribe, which was terminated in the 1960s and later reinstated without a reservation, has health clinics in the major cities in Nebraska and even when logistical barriers (scheduling, financial, travel, geography) are removed for Native veterans seeking care, “our veterans want to come to our [IHS] facility because of the cultural competency, care, and trust that they feel they have there.”

 Update on Native Copayment Implementation

In 2020, NCUIH worked with Chairman Tester and Ranking Member Moran on legislation meant to remove copayments for Native veterans receiving healthcare and extend this benefit to those who meet the statutory definition of the term ‘Indian’ or ‘Urban Indian’ set forth in the Indian Health Care Improvement Act. Unfortunately, the statute, which went into effect on January 5, 2022, is yet to be implemented. Senator Tester expressed his frustration to Mr. Upton that the VA hasn’t implemented the law to end copays for AI/AN healthcare at the VA, which “creates a disincentive for Native veterans to use the VA Healthcare facilities which is opposite of what should be occurring.” In September, VA Secretary Denis McDonough committed to putting this legislation into effect by the end of this year. Mr. Upton informed the Committee that the VA is looking into the ability to make the co-payment benefit retroactive, meaning that AI/AN veterans can be reimbursed for any co-pays they paid in 2022.

In a Federal Register notice concerning this issue, VA suggested that it is considering requiring Native veterans to show a Tribal identification card or a Certificate of Degree of Indian Blood (CDIB). Doing so would potentially exclude many eligible Native veterans and subvert Congress’ will to exempt all Native veterans meeting the definition of the term “Indian” or “Urban Indian” from VA copayments. For example, a Native veteran who is unhoused or low-income in an urban area may not have the ability to travel back to their Tribe to receive an identification card. That Native veteran might also have significant difficulty obtaining the required certified copy of a birth certificate needed to apply for a CDIB. In addition, in some cases, the Indian Health Care Improvement Act defines Indians and Urban Indians as descendants of Tribal citizens. Native veterans meeting that definition may not have the Tribal identification VA proposes to require. In her testimony, Ms. Tetnowski encouraged the VA to allow self-attestation in determining Native identity so that many Native veterans won’t be denied exemption from VA’s copayment rules.

Need for Increased Outreach and Technical Assistance for UIOs Regarding the VA Reimbursement Program

Thanks to NCUIH’s work with Congress on the passage of the Health Care Access for Urban Native Veterans Act of 2019 as part of the Consolidated Appropriations Act, 2021, UIOs are now eligible to enter the VA Reimbursement Agreements Program, which provides VA reimbursement to IHS, THP, and UIO health facilities for services provided to eligible AI/AN Veterans. Ms. Tetnowski called attention to the fact that, “many urban programs are experiencing difficulty enrolling, and only 1 of 41 completed the process” due to a lack of education and assistance for UIOs from the VA on this process. Ms. Tetnowski requested that the VA provide additional technical assistance and the ability to modify these agreements so that they work within the scope of services at their respective sites.

Need for an Urban Confer Policy with the VA

Urban Confer is an established mechanism for dialogue between federal agencies and UIOs. They are a response to decades of deliberate federal efforts (forced assimilation, termination, relocation) that have resulted in 70% of Native people living outside of Tribal jurisdictions. This has made Urban Confer integral to addressing the care needs of most Native people and is consistent with the federal government’s trust responsibility to AI/ANs. Failure to communicate about policies impacting urban Natives is not only inconsistent with the government’s trust responsibility, but it is contrary to sound public health policy. A VA Urban Confer Policy is especially important given that the majority of Native veterans live in urban areas. In her testimony, Ms. Tetnowski recalled when better communication was needed between the VA and UIOs during the rollout of COVID-19 vaccines, specifically with urban programs in Montana that didn’t receive as much of a supply, Some veterans who went to the VA to receive vaccines were told to go back to the ‘Indian clinic.’ This highlights the need for greater coordination among all entities serving our Native veterans.”

In June, the Health Equity and Accountability Act was introduced with the first-ever legislative text establishing an urban confer policy with the VA. Ms. Tetnowski went on to urge the Committee to include that language in future packages related to Native health care.

Next Steps:

The testimony will be read and considered by the Committee as it makes recommendations to the VA.

RESOURCE: COVID-19 Public Health Emergency Medicaid Unwinding Toolkit Released

The National Council of Urban Indian Health (NCUIH) recently released a Medicaid unwinding toolkit for urban Indian organizations (UIOs) as they prepare for changes in Medicaid coverage at the end of the COVID-19 pandemic Public Health Emergency (PHE). After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” This document outlines the impact of Medicaid unwinding on American Indians/Alaska Natives (AI/ANs) and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

Background

Medicaid Unwinding Toolkit

Prior to the pandemic’s PHE, Medicaid provided health insurance for more than one-third of AI/AN adults.  At the beginning of the pandemic, the Families First Coronavirus Response Act (FFCRA) Medicaid and Children’s Health Insurance Program (CHIP) “continuous coverage” requirement  allowed people to retain Medicaid coverage and receive needed care during the PHE.

Medicaid Unwinding Toolkit

After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” According to the Department of Health and Human Services (HHS), nearly 15 million people could lose their current coverage. This will be the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act (ACA). This process is expected to disproportionately impact AI/ANs, particularly those living off-reservation.

While the unwinding process will vary by state, each state will have up to 12 months to start an eligibility renewal for every individual enrolled in their entire Medicaid and CHIP population. The unwinding process will create several challenges and will result in a loss or gaps in coverage for individuals.

Impact on AI/AN Communities

Medicaid Unwinding Toolkit

AI/ANs may be at an increased risk of disenrollment in Medicaid and CHIP programs once the PHE ends. Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. Disenrollment of AI/ANs from Medicaid and CHIP will have significant consequences for the health and well-being of Native people – these programs are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Inadequate health insurance coverage is a significant barrier to healthcare access and often causes patients to delay or avoid medical care altogether. Alarmingly, when the PHE expires, 12% of all AI/AN children and 6% of all AI/AN adults nationwide are expected to lose CHIP or Medicaid coverage.

Medicaid Unwinding Toolkit

Medicaid-eligible AI/ANs face challenges in enrolling coverage due geographical remoteness, limited access to internet or phone service, language barriers, cultural factors, distrust of government programs, lack of knowledge of the benefits of coverage, or movement between non-reservation and reservation land.

Medicaid Unwinding and UIOs

UIOs play an important role in enrolling AI/ANs in Medicaid and CHIP as well as treating Medicaid beneficiaries, and will therefore, be critical in informing and helping eligible AI/AN maintain enrollment if eligible or explore other options. NCUIH’s resource highlights ways in which UIOs can work with states and other partners including Tribes and Tribal organizations, federal agencies like CMS and Indian Health Service (IHS), and their local communities:

Work with Your State

  • Request a meeting your state regarding unwinding.
  • Request that your state share renewal data via a spreadsheet or database so that you can speak with beneficiaries who utilize your services.
  • Work with your state to develop targeted communication for AI/AN communities about the state’s unwinding activities.
    • States can leverage Unwinding Communications Toolkit materials published by the Centers for Medicare & Medicaid Services (CMS).
    • Ask your state to provide AI/AN-specific guidance on maintaining coverage through Affordable Care Act (ACA) Marketplace plans for those no longer eligible for Medicaid. AI/AN beneficiaries may have access to low-cost zero and limited cost-sharing plans on the Exchanges.
  • Advocate that your state apply for Section 1902(e)(14)(a) waivers if necessary and applicable.

Work with Tribes

  • Collaborate with Tribes to request a meeting with your state regarding unwinding.
  • Develop partnerships with Tribes to provide necessary information to AI/AN beneficiaries.

Work with CMS, Indian Health Service (IHS), and Partner Organizations

  • Request consultation and confer with CMS and IHS to discuss coverage loss concerns and oversight.
  • Culturally appropriate materials are available through CMS, IHS, and the National Indian Health Board.

Work with Your Community

  • Work with beneficiaries to ensure that their contact information is updated with the state Medicaid office, including addresses, emails, and phone numbers, to ensure that individuals receive information on renewals.
  • Screen for potential Medicaid eligibility for all patients and refer current Medicaid recipients to your benefit specialists to update applications.
  • Engage community partners, health plans, and the provider community to encourage individuals to update their contact information and to provide assistance with renewals.
  • Educate patients, including utilizing outreach and educational materials in your clinic waiting rooms, patient rooms, and patient registration/in-take desks, regarding the unwinding and the risk of a loss in coverage.

CDC Seeking Nominations from Urban Indian Organizations for Project on Anti-Racism Practices and Policies

The Centers for Disease Control and Prevention Seeks Nominations of Health Care Organizations Currently Implementing Anti-Racism Practices and Policies

The Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke Prevention (DHDSP) is seeking nominations of health care organizations that are currently implementing anti-racism practices and policies with the potential to reduce health disparities and improve outcomes related to heart disease, stroke, and other cardiovascular disease conditions.  In partnership with NORC at the University of Chicago (NORC), the purpose of this project is to evaluate the impact of anti-racist practices on the delivery of health care and health equity. Eligible nominees include any health care organization or system, Tribal and Urban Indian health centers, school-based health centers, and outpatient community centers currently implementing anti-racism practices. Nominations are due by December 9, 2022 and should be submitted (2 pages or less) via email to: AntiRacismEval@norc.org.

Background

CDC’s DHDSP works with partners across government, public health, health care, and private sectors to improve prevention, detection, and control of heart disease and stroke risk factors, with a focus on high blood pressure and high cholesterol. DHDSP also works to improve recognition of the signs and symptoms of a heart attack or stroke and the quality of care following these events. Through its scientific and programmatic investments, DHDSP advances strategies such as using electronic health records to identify patients at risk and treat them appropriately and caring for patients with teams of clinicians, pharmacists, community health workers, and others outside of the doctor’s office. The division also promotes strategies that link patients to community programs and resources that help them take their medicines consistently, manage their risk factors, and make healthy lifestyle changes, such as quitting smoking or losing weight.

Nomination Eligibility and Information 

Any health care organization or system, including Tribal and Urban Indian health centers, school-based health centers, and outpatient community centers, that is currently implementing an anti-racism practice at the organizational, community, interpersonal and/or individual level. The intervention:

  • Focuses on dismantling racism, advancing health equity, or reducing health disparities among racial and ethnic minorities.
  • Focuses on cardiovascular disease or other chronic diseases
  • Has not yet undergone a comprehensive evaluation and has been implemented for at least 12 months.

Interested health organizations should include the following information:

  • Name and contact information for the primary point of contact
  • Description of the patient population at the location(s) where the anti-racism practice is being implemented, including the size of patient population, the percentage of patients that identify as non-white, and other demographic and social determinants of health characteristics.
  • A description of the anti-racism practice, including:
    • The anti-racism name
    • Implementation of the anti-racism practice began
    • The location(s) where the anti-racism practice is being implemented
    • The primary goals and the activities that comprise the anti-racism practices
    • The level(s) the implementation operates (i.e. individual, interpersonal, community, etc.)
    • The involvement of community members in the development and/or implementation of the anti-racism practice
    • The health condition(s) on which the anti-racism practice focuses
  • Any monitoring or evaluation history of the anti-racism practice including outcomes currently being monitored, methods used to monitor, and/or plans to monitor outcomes in the future.
  • The types of data available to support an evaluation of the anti-racism practice, such as EHR data, payer claims, registry data, or administrative records
  • A description of staff and data systems capacity to retrieve and share quantitative data reports on the anti-racism practice delivery, patient social determinants of health, and patient clinical outcomes with NORC’s evaluation team

When the nomination is complete, CDC will select up to six sites to participate in an evaluability assessment. Based on the outcome of the assessment, CDC will select up to three sites to participate in a rapid case study evaluation to further assess the impact of the anti-racism practice on the delivery of health care, health care access, and heart disease, stroke, or chronic disease outcomes.

All nomination sites will receive a selection decision by January 2023. If selected, virtual site visits and interviews will be scheduled in February 2023.

AI/AN Cardiovascular Health

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by cardiovascular disease (CVD), coronary heart disease (CHD), and overall poorer heart health. Stroke is also the sixth-leading cause of death for AI/ANs, who have the highest reported history of stroke compared with other US racial and ethnic groups.  According to the Health and Human Services Office of Minority Health report, in 2018, AI/ANs were 50 percent more likely to be diagnosed with coronary heart disease than their white counterparts.  Moreover, AI/AN adults were 10 percent more likely than white adults to have high blood pressure.  Compared to the general AI/AN population, urban AI/AN communities experience exacerbated health problems due to lack of family and traditional cultural environments in metropolitan areas. Recent studies of the urban AI/AN population have also documented poorer health status and reveal lack of adequate health care services as serious problems.

Call to Action 

Despite the disproportionate high rates of health disparities in AI/AN populations and specifically cardiovascular health, urban Indian organizations (UIOs) have continued to provide critical services aimed at addressing and combatting negative health outcomes through culturally competent care and programs. NCUIH encourages interested UIO leaders to submit nomination materials to antiracismeval@norc.org.

NCUIH Submits Comments to HRSA to Improve Access to Pediatric Health Care in Urban Native Communities

On August 31, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health Resources and Services Administration (HRSA) on the Pediatric Mental Health Care Access (PMCHA) Program. In a July 27 Dear Tribal Leader Letter, HRSA explicitly sought feedback from Urban Indian Organizations (UIOs) about how to increase access to and improve pediatric behavioral health care through telehealth and the PMCHA program’s development and implementation. NCUIH’s comments address the essential role of access to pediatric mental health care for American Indian/Alaska Native (AI/AN) communities across the country, including AI/AN communities in urban areas.

Background

According to the Indian Health Service (IHS), Native youth living off-reservation share similar health problems to their AI/AN peers nationwide, which are exacerbated by lack of access to family and traditional cultural environments. Notably, the AI/AN youth suicide rate is 2.5 times that of the national average.

UIOs are actively engaged in overcoming, addressing, and preventing mental and behavioral health issues in urban AI/AN youth. Virtually every UIO offers mental and behavioral health services, which became critically important during the height of the pandemic for families to continue accessing needed health care services to keep their doors open in the wake of reduced in-person visits. Since then, UIOs have continued to provide telehealth services to their patients, especially for mental and behavioral health programs.

Recommendations

NCUIH provided the following recommendations to HRSA regarding pediatric mental health care and telehealth services:

  • Facilitate UIO Participation in the PMHCA Program
    NCUIH urged HRSA to facilitate UIO participation in the PMHCA program. Although UIOs are a critical source of health care for urban AI/AN communities, they are often left underfunded and under resourced because federal grant programs unintentionally exclude UIOs. Accordingly, NCUIH suggested that whenever HRSA is asked to provide technical assistance on the PMHCA program to Congress, it advises Congress of this exclusion and a legislative fix to expand eligibility to UIOs. Any expansion of eligibility should be accompanied by a similar expansion in funding for the PMHCA program to ensure that there is no decrease in funding available for Tribes or Tribal organizations.
  • Continue to Engage with UIOs and Develop an Urban Confer Policy
    NCUIH recommended that HRSA continues to foster its relationship with UIOs through consistent and timely communication to UIOs. We further encouraged HRSA to cultivate meaningful partnerships between other federal agencies and stakeholders to notify UIOs when they are eligible for certain programs. Finally, NCUIH urged HRSA to develop an Urban Confer Policy, which would ensure HRSA’s services are more responsive to the needs and desires of urban AI/AN communities.

We will continue to monitor ongoing implementation of HRSA’s pediatric behavioral and mental health care programs that serve Indian Country.