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,

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.

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