NCUIH Recommendations Included in Report on Improving the Health and Safety of American Indian and Alaska Native Mothers and Infants

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On December 7, 2022, the Health and Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM) submitted a report to the Health and Human Services (HHS) Secretary Xavier Becerra titled: “Making Amends: Recommended Strategies and Actions to Improve the Health and Safety of American Indian and Alaska Native Mothers and Infants.” The report offers a set of recommended actions that could be among the many steps the Federal government may take, both to reconcile past actions and to step up to the obligations to American Indians and Alaska Natives (AI/AN) that it has abrogated since the founding of our nation. The National Council of Urban Indian Health (NCUIH) played an integral role in the report to ensure the needs of off-reservation AI/AN mothers were included. The report offers an analysis of the historic issues and current conditions facing AI/AN women and infants in the United States, through the lens of poor birth outcomes for AI/AN mothers and babies. It highlights a toxic legacy of genocide and trauma and acknowledges centuries of detrimental policies and programs that have disadvantaged and decimated AI/AN populations.

NCUIH has advocated on the behalf of urban AI/AN maternal and infant health and has worked closely with the ACIMM on AI/AN maternal and infant health issues. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Background

ACIMM focused its work on the birth outcomes of AI/AN mothers and infants because AI/AN populations are often overlooked in programmatic and policy discussions and investments even though their birth outcomes are among the worst in the country. Reasons for this oversight are numerous, including small population size, dispersed populations, lack of representation in decision-making spaces, and Tribes being non-state entities. The plight of AI/AN mothers and infants in the United States is a human rights issue that must be urgently addressed.

ACIMM’s report recommended three areas for strategic action framed on the premises of having healthy social and physical environment and access to high-quality care are essential to good birth outcomes; racism and the devaluing of AI/AN women disproportionately affects this population which negatively impact maternal and infant health outcomes and mortality; and AI/AN people have inherently protective practices embedded in their culture that contribute to their ongoing resilience.

  1. Make the health and safety of AI/AN mothers and infants a priority for action.
  2. Improve the living conditions of AI/AN mothers and infants and assure universal access to high quality healthcare.
  3. Address urgent and immediate challenges that disproportionately affect AI/AN women before, during, and after pregnancy.

Infant and Maternal Health Disparities in Native Health

According to the Office of Minority Health (OMH), Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

NCUIH’s work with AI/AN Maternal and Infant Health

The National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

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Supreme Court Held Oral Argument on Case Challenging the Indian Child Welfare Act

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On November 9, 2022, the Supreme Court of the United States held oral argument in Haaland v. Brackeen, a case challenging the constitutionality of the Indian Child Welfare Act of 1978 (ICWA). The questions presented to the Court in Brackeen are: (1) Whether various provisions of ICWA violate the anticommandeering doctrine of the Tenth Amendment; (2) Whether the individual plaintiffs have Article III standing to challenge ICWA’s placement preferences for “other Indian families,” and for “Indian foster home[s];” (3) Whether the default placement preferences for Indian homes in adoption or foster care cases are rationally related to legitimate governmental interests and therefore consistent with equal protection. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy and the National Council of Urban Indian Health (NCUIH) continues to advocate for the protection of ICWA to safeguard American Indian/Alaska Native (AI/AN) children and families.

Summary of Oral Argument

Oral argument for Brackeen lasted over three hours and focused heavily on the scope of Congress’s constitutional authority to legislate on behalf of AI/ANs, the equal protection limitations on that power, and whether the requirements imposed on states by the ICWA, particularly the “active efforts” requirement, violates the anticommandeering doctrine. Oral argument began with the parties challenging ICWA, referred to as “plaintiffs.” Solicitor General Judd Stone argued on behalf of the state of Texas, and Matthew McGill, a partner at Gibson, Dunn & Crutcher, argued on behalf of the potential adoptive families. The plaintiffs’ arguments centered on the assertion that ICWA deprives Indian children and non-Indian prospective parents of the “best interest of the child” standard in child welfare proceedings in violation of the Equal Protection Clause. The parties defending ICWA, referred to as “defendants,” argued second. Deputy Solicitor General Edwin Kneeler argued on behalf of the federal defendants and Ian H. Gershengorn, a partner at Jenner & Block, LLC , argued on behalf of the intervening Tribes (the Cherokee Nation, Oneida Nation, Quinault Nation, and Morongo Band of Mission Indians).  The defendant’ arguments centered on the fact that Congress has broad power to legislate in Tribal affairs, and this power is limited only by other constitutional provisions or by the test set by Supreme Court precedent in Morton v. Mancari, 417 U.S. 535 (1974), which requires congressional action to be rationally related to the fulfillment of Congress’ unique obligations to Indians.

Background on Haaland v. Brackeen

Congress enacted the ICWA in 1978 to re-establish Tribal authority over the adoption of AI/AN children. ICWA is a procedural safeguard to “protect the best interests of Indian children and to promote the stability and security of Indian Tribes and families.” 25 U.S.C. § 1902. In Brackeen, Texas, Indiana, Louisiana, and individual plaintiffs (plaintiffs) sued the federal government in the U.S. District Court for the Northern District of Texas, arguing that ICWA and its implanting regulations are unconstitutional because they violate the equal protection and substantive due processes provisions of the Fifth Amendment and violate the anticommandeering doctrine of the Tenth Amendment.  The plaintiffs also argued that ICWA and the implementing regulations violate the nondelegation doctrine and the APA. The District Court ruled in favor of the plaintiffs, finding that the ICWA violates the Constitution’s guarantee of equal protection because it applies to all children eligible for membership in a Tribe, not just enrolled tribal members, and therefore operates as a race-based statute.  The District Court further held that ICWA violates the Tenth Amendment’s prohibition on the federal government issuing direct orders to states and unconstitutionally delegates Congress’s power by giving Tribes the authority to change adoption placement preferences and make states abide by them. On appeal, the Fifth Circuit reversed the District Court’s opinion in most respects. In a fractured ruling, the Fifth Circuit sitting en banc upheld portions of the District Court’s opinion and reversed other portions.

In early September 2021, the United States government, tribal defendants, as well as state and private plaintiffs filed petitions asking the United States Supreme Court to review the Fifth Circuit’s decision. The U.S. Supreme Court agreed to review the Fifth Circuit’s decision in Brackeen v. Haaland on February 28, 2022, and held oral argument on November 9, 2022.

NCUIH Advocacy

On August 19, 2022, NCUIH and five urban Indian organizations (UIOs) (Nebraska Urban Indian Health Coalition, Inc., Sacramento Native American Health Center, Fresno American Indian Health Project, All Nations Health Center, and Oklahoma City Indian Clinic) signed on to the National Indigenous Women’s Resource Center’s (NIWRC) amicus brief to the Supreme Court in support of the constitutionality of ICWA in the  Haaland v. Brackeen case. NCUIH worked directly with NIWRC to engage with UIOs to ensure that the submitted brief was inclusive of urban AI/ANs. On September 7, NCUIH submitted written comments to the Bureau of Indian Affairs (BIA) and the Administration for Children and Families (ACF) on the BIA and ACF’s efforts to promote the consistent application of ICWA) and protect children, families, and Tribes.

NCUIH previously provided an in-depth analysis on the impact of ICWA and will continue to monitor ongoing developments.

Next Steps

The Supreme Court will hand down a decision by the end of the 2022 term on July 1, 2023. Due to the complex nature of the case, a decision is not expected until the Spring. The Supreme Court’s decision in Brackeen will have far-reaching implications on all areas of Federal Indian Law and policy. The recognition that the AI/AN classification is political classification rather than racial is a critical underpinning of not just ICWA, but many laws that relate to housing, healthcare, education, and employment. This political classification goes back to the 19th Century and has been upheld by Courts at multiple levels. Acknowledging the importance of tribal citizenship, AI/ANs are classified by this citizenship, not by their race.  If overturned, the repeal of ICWA would not only upend a law in place for more than 40 years but undercut the heart of tribal sovereignty and the federal government’s trust responsibility to Native communities.

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NCUIH Submits Comments to IHS Regarding the Office of Urban Indian Health Programs Strategic Plan and Implementation Plan

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On December 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) regarding additional input and recommendations for revisions to the third draft of the IHS Office of Urban Indian Health Programs (OUIHP) Strategic Plan and the Implementation Plan. The Strategic Plan and the Implementation Plan will be significant in guiding the provision of high-quality and culturally competent health care in fulfillment of the United States’ trust obligation to American Indian/Alaska Native (AI/AN) people. These comments were submitted in response to a November 17, 2022 Dear Urban Leader letter seeking input and recommendations for the final draft of the 2023-2027 IHS OUIHP Strategic Plan and Implementation Plan.

Background

In 2017, IHS developed an OUIHP Strategic Plan 2017-2021, pursuant to the Consolidated Appropriations Act, which described what the Agency hoped to achieve over the next 5 years. IHS is currently finalizing a new OUIHP Strategic Plan for 2023-2027 based on evaluations of the prior Strategic Plan along with participation and feedback received from urban Indian organization (UIO) leaders, IHS staff, and other stakeholders. According to the OUIHP, the new Plan will include goals, objectives, strategies, and performance measures, based on input from UIO Leaders, partners, and external stakeholders.

NCUIH’s Role

NCUIH has submitted three separate comments and recommendations to IHS regarding the Plan. These comments were based on NCUIH’s consultations with UIOs, the IHS Urban Confer held on December 15, 2022, and NCUIH’s subject matter expertise. NCUIH reiterated that input from UIOs is vital for IHS and its operating divisions to effectively gather comprehensive feedback, share critical information, and build mutual trust.

Recommendations

As OUIHP works to finalize the Strategic Plan for 2023-2027, NCUIH made numerous recommendations to strengthen the OUIHP strategic plan.  Among these recommendations were keeping strategic pillars from the prior draft regarding facilitating communication with federal partners on UIO issues and to provide technical assistance to UIOs transitioning from an outreach and referral program to an ambulatory clinic. Further, NCUIH recommended revisions on a strategic pillar to retain strategies regarding receiving 100% Federal Medical Assistance Percentage (FMAP) for UIOs.

NCUIH thanks the OUIHP for the hard work in developing this comprehensive third draft and for conferring with UIOs on additional recommendations. NCUIH also appreciates the opportunity to provide additional comments and recommendations on the OUIHP Strategic Plan Draft 3.  NCUIH strongly believes that the Strategic Plan and the Implementation Plan are important vehicles to articulate leadership priorities, provide direction for program management functions, engage external partners and entities, and measure OUIHP’s progress toward meeting the goals and objectives of IHS. NCUIH looks forward to the final version of the 2023-2027 Strategic Plan and to working with OUIHP to ensure both the Strategic Plan and Implementation Plan are successful.

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White House National Strategy on Hunger, Nutrition, and Health Outlines IHS Produce Prescription Program, Urban Indian Organizations Eligible

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On September 27, 2022, during the White House Conference on Hunger, Nutrition, and Health, the Biden-Harris Administration released the National Strategy on Hunger, Nutrition, and Health (the Strategy). The Strategy outlines actions the Administration aims to take to reach its goal “to end hunger in America and increase healthy eating and physical activity by 2030 so fewer Americans experience diet-related diseases” and commits that the Indian Health Service (IHS) will implement and evaluate a National Produce Prescription Pilot Program, which urban Indian organizations (UIOs) are eligible to participate in. It also recognizes that States should collaborate with non-profit or community-based organizations to establish state-funded produce prescription programs (PPPs) for low-income individuals and families. According to the Strategy, produce prescriptions are “fruit and vegetable prescriptions or vouchers provided by medical professionals for people with diet-related diseases or food insecurity” and can “effectively treat or prevent diet-related health conditions and reduce food insecurity.”

Pillar 2 of the Strategy seeks to “ensure that our health care system addresses the nutrition needs of all people” and further outlines how IHS can implement and evaluate a National Produce Prescription Pilot Program. The Fiscal Year (FY) 2022 funding bill authorized $3 million for the Indian Health Service (IHS) to create a Produce Prescription Pilot program in coordination with Tribes and UIOs to increase access to produce and other traditional foods for American Indians/Alaska Natives (AI/ANs). This pilot program was also included in the recently passed FY 2023 funding bill and maintained at FY 2022 funding levels. Currently, the American Indian Health and Family Services (AIHFS), a Title V UIO located in Detroit, Michigan, is already operating a produce prescription program called Fresh RX.

About Produce Prescription Programs (PPPs)

PPPs are medical treatment or preventative services for patients who are eligible due to diet-related health risks or conditions, food insecurity, or other documented challenges in access to nutritious foods, and are referred by a healthcare provider or health insurance plan. These prescriptions are fulfilled through food retail and enable patients to access healthy produce with no added fats, sugars, or salt, at low or no cost to the patient. PPPs are designed to improve healthcare outcomes, optimize medical spending, and increase patient engagement and satisfaction.

The National Produce Prescription Coalition (NPPC) is a coalition that aims to leverage PPPs as prevention and intervention for diet-related disease and further embeds this effective model into healthcare and food retail systems. The goal is to embed PPPs as a covered benefit for members of all government-sponsored health plans whose healthcare providers and case managers diagnose as having or having elevated risk for diet-related illness as well as having or having elevated risk for food insecurity. This includes Medicaid and the CHIP, Medicare and Medicare Advantage, as well as beneficiaries of IHS.

The NPPC Policy Platform includes:

  • Indian Health Service: Utilize congressional appropriation and significant philanthropic support to advance a PPP demonstration project and establish standards for utilization within IHS.

AI/ANs and Nutrition and Health

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

NCUIH Advocacy

The Administration sought input on the development and implementation of this Strategy and initiated Tribal Consultation on June 28, 2022. On July 15, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Administration, the Department of Health and Human Services (HHS), and the US Department of Agriculture (USDA) and recommended that they support UIOs to promote food security, nutrition, and exercise; include urban AI/AN populations in future research efforts and government projects; and establish consistent Urban Confers regarding nutrition, hunger, and health.

On September 28, 2022, Walter Murillo (Choctaw), CEO of NATIVE Health and President-Elect of NCUIH, headlined a panel titled “Breaking Barriers: Bridging the Gap Between Nutrition and Health” at the White House Conference on Hunger, Nutrition, and Health, where they unveiled the Strategy. Mr. Murillo highlighted high rates of food insecurity in Indian Country, which intersects with other social determinants of health such as limited housing, employment, and lack of trust in health care systems in Native communities.

NCUIH will continue to monitor program updates in the Strategy and the IHS National Produce Prescription Pilot Program.

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HHS Launches New Maternal Health Resources for American Indian and Alaska Native Communities

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On December 1, 2022, the U.S. Department of Health and Human Services(HHS) Secretary Xavier Becerra attended the White House Tribal Nations Summit where he discussed the Department’s commitment to addressing mental and maternal health in American Indian and Alaska Native (AI/AN) communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.

Background on Hear Her Campaign

The CDC’s Division of Reproductive Health launched the Hear Her in 2020 as a national campaign that brings attention to pregnancy-related deaths and provide education and encouragement to pregnant and postpartum women (within one year of delivery).  The campaign supports CDC’s efforts to prevent pregnancy-related deaths by sharing potentially life-saving messages about urgent warning signs.

The Hear Her campaign was launched because too many people die from pregnancy-related complications. Alarmingly over 700 women die each year in this country from problems related to pregnancy or delivery complications. Every death is a tragedy, especially when two thirds of pregnancy-related deaths could be prevented. As many as 50,000 women experience severe, unexpected health problems related to pregnancy that may have long-term health consequences. Additionally, there are significant racial and ethnic disparities in pregnancy-related complications and deaths.  The Hear Her campaign centers on the stories of women who have experienced pregnancy-related complications.  Recognizing urgent maternal warning signs and getting an accurate and timely diagnosis can save lives during pregnancy and up to a year after delivery.

AI/AN Infant and Maternal Health Disparities

According to the OMH, Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Given the maternal health disparities that AI/AN people and communities experience, it is a priority for CDC and OMH to reach tribal communities with resources CDC and OMH have worked to include the voices and perspectives of AI/AN throughout the development of the campaign and will continue to do so over time. As the campaign moves forward into implementation, the focus will be on building capacity for tribes and tribal serving organizations to implement the campaign and improve maternal outcomes.

UIO and NCUIH work in AI/AN Infant and Maternal Health

Urban Indian organizations (UIOs) provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

 

Furthermore, the National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, NCUIH submitted comments to HRSA Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of HHS on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality, and sever maternal morbidity and improving the health status of infants and women before, during, and after pregnancy. Moreover, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also recently released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

In addition to written advocacy, NCUIH has been invited to present on urban AI/AN maternal and infant health. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

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NCUIH Submits Comments to the Department of Veterans Affairs and IHS on VHA-IHS Memorandum of Understanding Operational Plan

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On November 30, 2022, NCUIH submitted comments to the U.S. Department of Veterans Affairs (VA) and the Indian Health Service (IHS) regarding the Veterans Health Administration (VHA) and IHS first-ever Draft Annual Operational Plan for fiscal year (FY) 2022 for the VHA-IHS Memorandum of Understanding (MOU). The MOU establishes a framework for coordination and partnership between VHA and IHS to leverage and share resources and investments in support of each organization’s mutual goals. NCUIH believes that the Draft Annual Operational Plan (Operational Plan) can be a significant step forward in implementing the IHS-VHA MOU and ensuring high quality health care for all American Indian/Alaska Native (AI/AN) veterans and continues to work closely with our colleagues at VA and IHS to ensure that Native veterans receive access to the care they earned through their military service, no matter where they live.

Background

AI/AN 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. In return for their service, the United States promised all veterans, including Native veterans, “exceptional health care that improves their health and well-being.” However, of the estimated 86.2 percent of AI/AN veterans that live in urban areas, they generally have higher unemployment, lower education attainment, lower income, higher VA-service connected disability, and generally live in poorer housing conditions than non-Native veterans also living in urban areas.

Recommendations

In its comments, NCUIH stressed the importance of the Operational Plan being a vehicle to articulate leadership priorities, provide direction for program management and distribution of resources, engage internal and external partners, and measure the overall progress toward meeting the MOU’s goals and objectives. NCUIH’s comments emphasized the importance of having OUIHP representation and leadership throughout the plan. As subject matter experts in the health needs of Natives living in urban areas, having representatives who are familiar with UIOs will ensure the needs of urban Native veterans are incorporated into the plan’s actions. Additionally, to improve the collaboration between the VA and IHS, and to ensure that care for AI/AN veterans is not disrupted, NCUIH recommended that the Operational Plan has a strategy in place to achieve seamless referrals between the VA and the I/T/U system. NCUIH further stressed the importance of regular consultation with Tribal Governments, Urban Confers with UIOs, and meetings with the HHS Secretary’s Tribal Advisory Committee on Tribal and Indian Affairs.  Moreover, because VA data currently indicates that Native veterans use Veterans Benefits Administration benefits or services at lower percentages than other veterans, NCUIH recommended that the Operational Plan add an additional objective be added to increase AI/AN veteran use of VA benefits and services.

NCUIH’s work with the VA

NCUIH continues to work on behalf of Native veterans living in urban areas to ensure that they have access to the high-quality, culturally competent care the country owes to them for their military service and as a result of the trust responsibility.

For more information on NCUIH’s efforts please visit:

 

 

 

 

 

 

 

 

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Maternal, Infant, and Early Childhood Home Visiting Program Reauthorization Included in Final Appropriations Package with Tribal Set-Aside Increase

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On December 29, 2022, the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (H.R. 8876) was included in the final appropriations package, also known as the omnibus, for Fiscal Year (FY) 2023. Notably, the omnibus reauthorized the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and increased funding through FY 2027. The program supports home visit programs, including the Tribal Home Visiting Program (THVP), for expectant and new parents who live in communities that are at risk for poor maternal and child health outcomes. To continue improving the infant and maternal health of American Indian/Alaska Native (AI/AN) communities, the bill provides a notable improvement to the THVP program by (from 3% to 6%) starting in FY 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the reauthorization of MIECHV and increasing funding for the Tribal set-aside and continues to advocate on behalf of AI/AN mothers and infants.

In addition, the bill makes several to the MIECHV program overall, such as:

  • $500,000,000starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.
  • Dedicates a 2% set-aside for workforce support, retention, and case management.
  • Allows set-asides for research, evaluation, and administration (3%) and technical assistance (2%).
  • Creates an “outcomes dashboard” to help Congress and the public track MIECHV’s success in improving family outcomes.
  • Annual report to Congress to better oversee the program and make improvements in the future.

Background

The Tribal Home Visiting Program

Since 2010, a 3% set-aside has been allotted to the THVP, a program administered within MIECHV to specifically support and promote the health and well-being of AI/AN families.

From the MIECHV 2015 Congressional Report, THVP grantees, including urban Indian organizations (UIOs), served 870 families—5 times the number served in FY 2012. Nearly 20,000 home visits were provided to 3,197 adult participants and children between FY 2012 and FY 2014. After 3 years of implementation, 77% of grantees also demonstrated overall improvement in several benchmark areas. These include:

  • 62% improvements in maternal and newborn health
  • 85% increase in the prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits
  • 69% improvement in school readiness and achievement
  • 77% reduction in crime or domestic violence
  • 77% improvement in family economic self-sufficiency
  • 69% improvements in the coordination and referrals for other community resources

Since its inception, the THVP has been an influential program to help improve the development of healthy AI/AN children and families through coordinated, culturally relevant, and evidence-based home-visiting strategies addressing critical maternal and child health needs.

NCUIH Advocacy

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants for increased funding and support to the UIOs that provide maternal health, infant health, prenatal, and family planning services. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing the MIECHV program and doubling the Tribal set-aside, which includes UIOs.

NCUIH also submitted comments on March 10, 2022, to the Health Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. On August 31, 2022, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In those comments, NCUIH continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, presented before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Thanks to this NCUIH advocacy, H.R. 8876 included language to double the Tribal set-aside from 3% to 6% in FY 2023, which was ultimately included in the final appropriations package for FY 2023.

AI/AN Maternal Health Disparities

American Indian and Alaska Native (AI/AN) communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. A report by the National Center for Health Statistics noted that between 2005 and 2014, AI/ANs were the group that did not experience a decline in infant mortality.

Over half of UIOs provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).

Through expanded research efforts, many factors have been directly identified as reasons for AI/AN infant and maternal health disparities. These include:

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Final FY2023 Omnibus Bill Includes Advance Appropriations for the Indian Health Service and Several Other Priorities

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The bill includes $6.96 billion for IHS and $90.42 million for urban Indian health.

On December 29, 2022, the Consolidated Appropriations Act, 2023 (H.R. 2617) for fiscal year (FY) 2023, also known as the ‘omnibus,’ was signed into law by President Biden. This follows a third continuing resolution for FY2023 through December 30. The bill passed in the Senate with a 68-29 vote followed by a House passage of a 221-205-1 vote. The 4,155-page omnibus bill authorizes $6.96 billion for the Indian Health Service (IHS) for FY 2023, a $360 million increase above the FY 2022 enacted level; advance appropriations for IHS totaling $5.13 billion for FY 2024; and $90.42 million for urban Indian health for FY 2023. In addition, the final package includes increased funding to expand behavioral health services and programs eligible to urban Indian organizations (UIOs).

The National Council of Urban Indian Health (NCUIH) has long advocated for larger investments in American Indian and Alaska Native (AI/AN) health care and has called on Congress to strengthen its commitment to Indian Country with increased funding in the FY 2023 appropriations. Unfortunately, despite robust NCUIH advocacy, the bill does not include an extension of 100% Federal Medical Assistance Percentage (FMAP) for UIOs or an Urban Confer policy with the Department of Health and Human Services (HHS). NCUIH will continue to advocate for these priorities in future legislation.

The Tribal Budget Formulation Workgroup (TBFWG), a national workgroup that identifies annual Tribal funding priorities, requested full funding for IHS at $49.9 billion and $949.9 million for urban Indian health. While the bill provides a key Indian Country request for advance appropriations for IHS, unfortunately, the final amount still falls short of fully funding IHS so that the agency can properly provide health care services for all AI/ANs.

To read NCUIH’s joint press release with the National Indian Health Board (NIHB) and the National Congress of American Indians (NCAI) on the inclusion of IHS advance appropriations in the omnibus, click here.

Bill Text:
Overview of IHS and Urban Indian Health Requests
Line Item FY22 Enacted FY23 TBFWG Request FY23
President’s
Budget		 FY23
House Passed		 FY23 Senate Proposed FY23 Omnibus
Urban Indian Health $73.43 million $949.9 million $112.5 million $200 million $80.4 million $90.4 million
Indian Health Service $6.6 billion $49.8 billion $9.3 billion – Mandatory funding* $8.1 billion $7.38 billion $6.9 billion
Advanced Appropriations ——————- ———————- ————— —————- $5.6 billion $5.1 billion
Hospitals and Clinics $2.3 billion $8.66 billion $3.4 billion $2.8 billion $2.8 billion $2.5 billion
TECs $24.4 million $24.4 million $24.8 million $34.4 million $34.4 million $34.4 million
EHRs $145 million $451 million $284.5 million $284.5 million $217.5 million $217.5 million
CHRs $63.6 million $1.4 billion $68.8 million $65.2 million $67 million $65.2 million
Direct Operations $95 million $98.4 million $115.4 million $135.4 million $103.8 million $103.8 million
Mental Health $121.9 million $3.9 billion $199.1 million $130 million $127.1 million $127.1 million
BIA MMIW $24.9 million ——————– ————— $25.1 million $25.1 million $25.1 million
Key Provisions for IHS, Tribal Organizations, and UIOs
  • $6.9 billion for IHS for FY 2023
  • $90.4 million for urban Indian health for FY 2023
  • $5.1 billion for Advance Appropriations for FY 202
  • $24 million for the Good Health and Wellness in Indian Country Program
  • $15.6 million to make payments under the National Health Service Corps Loan Repayment program
  • $80 million authorized to be appropriated through FY2023-FY2027 for Native Behavioral Health Access Grants
  • Reauthorizes and establishes scheduled funding increases for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubles the Tribal set-aside from 3% to 6% for the Tribal Home Visiting Program
  • Fully funds Contract Support Costs and Payments for Tribal Leases
Analysis

Urban Indian Health

  • $90,419,000 for urban Indian health for FY 2023

Indian Health Service

  • $5,129,458,000 in advance appropriations for IHS for FY 2024
  • $6,958,223,000 in agency funding for IHS in FY 2023
    • Indian Health Services – $4,890,282,000
  • Hospitals and Health Clinics – $2,503,025,000
  • Tribal Epidemiology Centers (TECs) – $34,400,000
  • Electronic Health Records (EHRs) – $217, 564,000
  • Community Health Representative (CHRs) – $65,212,000
  • Mental health – $127,171,000
  • Direct Operations – $103,805,000
  • Indian Health Care Improvement Fund – $74,138,000
  • Indefinite appropriation to fully fund Contract Support Costs at $969,000,000 for FY 2023
  • Indefinite appropriation to fully fund payments for 105(l) leases at $111,000,000 for FY 2023
  • Funds Indian Health Facilities at $958,553,000

Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)

  • Native Hawaiian Health Care
    • $27,000,000
  • National Health Service Corps (NHSC)
    • $15,600,000 to Indian Health Service facilities, Tribally Operated Health Programs, and Urban Indian Health Programs to make payments under the NHSC loan repayment program.
  • Center of Excellence for Eating Disorders – Screening and Referrals
    • $1,000,000 through FY 2027
      • Funding for training and technical assistance to primary and behavioral health providers and non-clinical community support workers to identify treatment and provide ongoing support to individuals with eating disorders

Centers for Disease Control and Prevention (CDC)

  • Good Health and Wellness in Indian Country (GHWIC)
    • $24,000,000
  • Minority HIV/AIDS Prevention and Treatment Program
  •  $5,000,000 Tribal set-aside under the Minority HIV/AIDS Prevention and Treatment Program

Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing)

  • Medication-Assisted Treatment for Prescription Drug and Opioid Addiction
    • $14,500,000
  • Peer-Supported Mental Health Services
    • $13,000,000 for each of fiscal years 2023 through 2027
      • A new grant program with direct UIO eligibility
  • Infant and Early Childhood Mental Health Promotion, Intervention and Treatment
    • $50,000,000 for fiscal years 2023 through 2027
  • Behavioral Health and Substance Use Disorder Resources for Native Americans
    • $80,000,000
    • Ensures HHS consult with Indian Tribes and Tribal organizations, confer with UIOs, and engage with Native Hawaiian health organization regarding the administration of funding
  • Mental and Behavioral Health Education and Training Grants
    • $31,700,000 for each fiscal year 2023-2027
      • The training demonstration has I/T/U eligible entities
  • State Opioid Response (SOR) Grants
    • $55,000,000
    • UIOs not eligible
  • Tribal Behavioral Health grant (formally known as Native Connections)
  • Reauthorized for fiscal years 2023 through 2027

Bureau of Indian Affairs (BIA)

  • Missing and Murdered Indigenous Women (MMIW)
    • $24,898,000 for Law Enforcement Special Initiatives, of which an additional $5,000,000 is to continue addressing the MMIW effort
  • Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans
    • that each VA medical center has a full-time minority veteran coordinator who must receive training in the delivery of culturally appropriate mental health and suicide prevention services to AI/AN veterans
  • Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)
    • Reauthorizes and establishes scheduled funding increases for the MIECHV and doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program
    • $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027
  • Native Boarding School Initiative
    • $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative
  • Violence Against Women Act (VAWA) – $25,000,000
    • $500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women
    • $11,000,000 is to assist tribal exercising special Tribal criminal jurisdiction
    • $3,000,000 is for an initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys
Topic Section Funding Language
Urban Indian Health Urban Indian Health $90,419,000 Pg. 69
“The agreement includes $90,419,000 for the Urban Indian health program, which includes the reallocation of former NIAAA funds.”
Indian Health Service (IHS) Advanced Appropriations $5,129,458,000 Pg.67
‘The agreement provides advance appropriations for the Indian Services and Indian Health Facilities accounts totaling $5,129,458,000 for fiscal year 2024.”
IHS Funding $6,958,233,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS )”
Indian Health Services $4,890,282,000 Pg.67:  
“The bill provides a total of $6,958,223,000 for the Indian Health Service (IHS ), of which $4,890,282,000 is for the Services account”
Hospitals and Clinics $2,503,025,000 Pg.68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health. This amount also includes requested reallocation of prior year staffing funds for the Phoenix Indian Medical Center, Cherokee Nation, and United Keetoowah Band. The agreement maintains funding at fiscal year 2022 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program. The agreement also continues funding at the fiscal year 2022 enacted levels for the domestic violence prevention program, accreditation emergencies as discussed in the House report, health information technology, healthy lifestyles in youth project, and the National Indian Health Board cooperative agreement.”
TECs $34,433,361 Pg. 68
“The agreement provides $2,503,025,000 for Hospitals and Health Clinics, which includes an additional $10,000,000 for Tribal epidemiology centers, $2,000,000 for village built clinics, and an additional $1,000,000 to improve maternal health.”
EHRs $217,564,000 Pg. 69
“The agreement provides $217,564,000 for Electronic Health Records (EHR), which includes an increase for uses as requested.”
CHRs $65,212,000 Pg. 274: See Chart for Language
Mental Health $127,171,000 Pg. 69
“The bill provides $127,171,000 for Mental Health, which continues funding at fiscal year 2022 enacted levels for the behavioral health integration initiative, for suicide prevention, and for the Tele-behavioral Health Center of Excellence and includes the requested reallocation of staffing funds”
Direct Operations $103,805,000 Pg. 70
“The bill provides $103,805,000 for direct operations, which includes an increase of $5,000,000 for quality and oversight, for uses as requested, and an increase of $1,000,000 for management and operations.”
Indian Health Care Improvement Fund $74,138,000 Pg. 274: See Chart for Language
Contract Support Costs $969,000,000 Pg. 70:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund contract support costs, which are estimated to be $969,000,000 in fiscal year 2023.”
105(l) leases $111,000,000 Pg. 74:
“The bill continues language from fiscal year 2022 providing an indefinite appropriation to fully fund payments for Tribal leases, which are estimated to be $111,000,000 in fiscal year 2023.”
Indian Health Facilities $958,553,000 Pg. 70
“The bill provides $958,553,000 for Indian Health Facilities.
Costs for accreditation emergencies and supplementing activities funded under the heading ‘‘Indian Health Facilities’’ $58,000,000 Pg.878:
“That of the funds provided, $58,000,000 shall be for costs related to or resulting from accreditation emergencies, including supplementing activities funded under the heading ‘‘Indian Health Facilities,’’ of which up to $4,000,000 may be used to supplement amounts otherwise available for Purchased/
Referred Care”
Health and Human Services (HHS) HRSA—
Hawaiian Health Care Program		 $27,000,000 Pg.10
The agreement includes no less than $27,000,000 for the Native Hawaiian Health Care Program, of which not less than $10,000,000 shall be provided to Papa Ola Lokahi for administrative purposes authorized under 42 U.S.C. 11706, including to expand research and surveillance related to the health status of Native Hawaiians and strengthen the capacity of the Native Hawaiian Health Care Systems.”
HRSA—
NHSC Loan Repayment Program		 $15,600,000 Pg. 991:
“That, within the amount made available in the previous provison, $15,600,000 shall remain available until expended for the purposes of making payments under the NHSC Loan Repayment Program under section 338B of the PHS Act to individuals participating in such program who provide primary health services in Indian Health Service facilities, Tribally-Operated 638 Health Programs, and Urban Indian Health Programs (as those terms are defined by the Secretary), notwithstanding the assignment priorities and limitations under section 333(b) of such Act”
CDC—
Good Health and Wellness in Indian Country		 $24,000,000 Pg. 33: See Chart for Language
CDC—
Minority HIV/AIDS Prevention and Treatment Program		 $5,000,000 Pg.130
Tribal Set-aside.-The agreement includes an increase of $2,000,000 for a Tribal set-aside within the Minority HIV/AIDS Prevention and Treatment program.
Important Behavioral and Mental Health Provisions (Restoring Hope For Mental Health And Wellbeing) Medication-Assisted Treatment for Prescription Drug and Opioid Addiction $14,500,000 Pg. 104
“The agreement directs SAMHSA to ensure that these grants include as an allowable use the support of medication-assisted treatment and other clinically appropriate services to achieve and maintain abstinence from all opioids, including programs that offer low-barrier or same day treatment options. Within the amount provided, the agreement includes $14,500,000 for grants to Indian Tribes and Tribal Organizations.”
Peer-Supported Mental Health Services $13,000,000
for FY23-FY27		 Pg. 3067
“There is authorized to be appropriated to carry out this section $13,000,000 for each of fiscal years 2023 through 2027.’’
Infant and Early Childhood Mental Health Promotion, Intervention and Treatment $50,000,000
for FY23-FY27		 Pg. 3177
“in subsection (g) (as redesignated by paragraph (1)), by striking ‘‘$20,000,000 for the period of fiscal years 2018 through 2022’’ and inserting ‘‘$50,000,000 for the period of fiscal years 2023 through 2027’’.
Behavioral Health and Substance Use Disorder Resources for Native Americans $80,000,000
for FY23-FY27		 Pg. 3072
“There are authorized to be appropriated to carry out this section, $80,000,000 for each of fiscal years 2023 through 2027.’’
Mental and Behavioral Health Education and Training Grants $31,700,000
for FY23-FY27		 Pg. 3171
‘‘$10,000,000 for each of fiscal years 2018 through 2022’’  and $31,700,000 for each of fiscal years 2023 through 2027”
State Opioid Response (SOR) Grants $55,000,000 Pg. 1016:
“That of such amount $55,000,000 shall be made available to Indian Tribes or tribal organizations”
Tribal Behavioral Health grant (formally known as Native Connections) Reauthorized Pg. 3044:
“PRIORITY MENTAL HEALTH NEEDS OF REGIONAL AND NATIONAL SIGNIFICANCE.—Section 520A of the Public Health Service Act (42 U.S.C. 290bb–32) is
amended […](2) in subsection (f), by striking ‘‘$394,550,000 for each of fiscal years 2018 through 2022’’ and inserting ‘‘$599,036,000 for each of fiscal years 2023 through 2027’’.”
Bureau of Indian Affairs (BIA) and Bureau of Indian Education at the Department of the Interior (DOI) for Law Enforcement Special Initiatives – MMIW Effort $25,094,000 Pg.37
“The agreement includes $25,094,000 for Law Enforcement Special Initiatives, which continues funding at enacted levels for the MMIW Tribal Public Safety initiative, Tiwahe recidivism initiative, equipment to collect and preserve evidence at crime scenes, and victim witness specialists.”
Native Boarding School Initiative $19,409,000 Pg.37
“The bill includes $263,766,000 for Executive Direction and Administrative Services, of which: $19,409,000 is for Assistant Secretary support, which maintains funding to implement the PROGRESS Act, the Diversity and Inclusion program for BIA and OST, and the Native boarding school initiative.”
Mental Health and Suicide Prevention Outreach to Minority Veterans and American Indian and Alaska Native Veterans N/A Pg.2652
“Not later than 180 days after the date of the enactment of this Act, the Secretary, in consultation December 19, 2022 with the Director of the Office of Mental Health and Suicide Prevention, shall ensure that the suicide prevention coordinator and minority veteran coordinator of each medical center of the Department have developed and disseminated to the director of the medical center a written plan for conducting mental health and suicide prevention outreach to all tribes and urban Indian health organizations within the catchment area of the medical center.”
Tribal Home Visiting Program and Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) $500,000,000 starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.

Doubles the set-aside from 3% to 6% for the Tribal Home Visiting Program

 Page 3883:
“(B) in subparagraph (A)— (i) by striking ‘‘3’’ and inserting ‘‘6’’; (ii) by inserting ‘‘and administering’’ before ‘‘grants’’;”
Violence Against Women Act (VAWA) National clearinghouse that provides training and technical assistance on issues relating to sexual assault of AI/AN women $500,000 Pg. 178
“$500,000 is for a national clearinghouse that provides training and technical assistance on issues relating to sexual assault of American Indian and Alaska Native women.”
Assist tribal exercising special Tribal criminal jurisdiction $11,000,0000 Pg. 178
‘$11,000,000 is for programs to assist Tribal Governments in exercising special Tribal criminal jurisdiction, as authorized by section 204 of the Indian Civil Rights Act.”
Initiative to support cross-designation of Tribal prosecutors as Tribal Special Assistant United States Attorneys $3,000,0000 Pg. 179
‘$3,000,000 is for an initiative to support cross-designation of tribal prosecutors as Tribal Special Assistant United States Attorneys.”

NCUIH Contact: Lycia Maddocks (Ft. Yuma Quechan), Director of Congressional Relations, lmaddocks@ncuih.org

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NCUIH, NIHB, and NCAI Celebrate Historic Inclusion of Advance Appropriations for the Indian Health Service

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FOR IMMEDIATE RELEASE

Washington, DC | Friday, December 23, 2022 – Today, Congress enacted a Fiscal Year (FY) 2023 omnibus spending package, including a historic provision providing advance appropriations for the Indian Health Service (IHS). Prior to this change, IHS was the only federal healthcare provider without basic certainty of funding from one year to the next.

The Indian health system serves approximately 2.5 million patients at IHS, Tribal facilities, and urban Indian organizations, and was created to meet the U.S. trust responsibility to raise the physical, mental, social, and spiritual health of all Native people to the highest standard. Unfortunately, Indian healthcare remains chronically underfunded – a U.S. policy exacerbated by disruptions in the discretionary appropriations process.

With advance appropriations, American Indians and Alaska Natives will no longer be uniquely at risk of death or serious harm during delays in an FY 2024 funding agreement. Inclusion of IHS advance appropriations in the spending bill means that IHS services will be protected from the harmful effects of disruptions in federal funding for FY 2024 because Congress has agreed to an amount this year that becomes available immediately on October 1, 2023.

“We applaud Congress and the White House for listening to Native communities and doing what is right. For far too long, the federal government has allowed political disputes over budgets to jeopardize the lives of American Indian and Alaska Native people. Every single time there is a stopgap budget, the funding for urban Indian health clinics is deferred and reduced. This compromises the delivery of health care. We look forward to working with our leaders to help the United States make good on its responsibility to provide health care for the people who gave up the land we are on today.” 

  • Sonya Tetnowski (Makah), President of the National Council of Urban Indian Health  

“Including advance appropriations for Indian health in the omnibus is a historic moment for Indian Country over a decade in the making. While Indian health remains chronically underfunded, this provision will help ensure that the Indian Health Service can provide stable, uninterrupted care to our people even when there is a government shutdown. We are confident that we can build on this win and continue our work toward full and mandatory funding for the Indian Health Service, fulfilling the promises this country made to our people over two centuries ago.” 

  • William Smith (Valdez Native Tribe), President of the National Indian Health Board  

“The National Congress of American Indians (NCAI) in partnership with our invaluable allies at the National Indian Health Board (NIHB) and the National Council of Urban Indian Health (NCUIH) have fought for years to get advanced appropriations for the Indian Health Service (IHS) and commends Congress for taking this critically important step for Indian Country. This historic decision comes not a moment too soon as Indian Country continues to be plagued by an ongoing health crisis that affects all of our communities. This week’s action represents a meaningful step taken by the United States towards fulfilling its trust and treaty responsibilities to Tribal Nations and we are grateful for it as we continue to call on the United States to make good on all of its promises made to our ancestors so that our communities may continue to thrive.” 

  • Fawn Sharp (Quinault Indian Nation), President of the National Congress of American Indians 

This success would not have been possible without all the advocacy from Tribes, Tribal organizations, and Urban Indian Organizations. As part of this effort, the National Indian Health Board, the National Congress of American Indians, and the National Council of Urban Indian Health have been part of a broad coalition of advocates and champions for IHS advance appropriations. Our organizations would like to thank the coalition for its dedication and leadership during this endeavor.

We would like to also provide special thanks to Leader Schumer, Speaker Pelosi, and the Biden-Harris administration for championing this historic change, as well as House and Senate appropriators, the Senate Committee on Indian Affairs, the House Committee on Natural Resources, the House Native American Caucus, and all of Indian Country’s champions throughout Congress. Finally, we would like to thank Office of Management and Budget Director Shalanda Young, Department of Health and Human Services (HHS) Secretary Becerra, IHS Director Roselyn Tso, and all the OMB and HHS staff who worked tirelessly to realize this moment.

Together, we made history.

###

About The National Council of Urban Indian Health (https://ncuih.org/)
The National Council of Urban Indian Health (NCUIH) is the national non-profit organization devoted to the support and development of quality, accessible, and culturally competent health and public health services for American Indians and Alaska Natives (AI/ANs) living in urban areas. NCUIH is the only national representative of the 41 Title V Urban Indian Organizations (UIOs) under the Indian Health Service (IHS) in the Indian Health Care Improvement Act (IHCIA). NCUIH strives to improve the health of the over 70% of the AI/AN population that lives in urban areas, supported by quality, accessible health care centers. 
Media Contact: Meredith Raimondi, Vice President of Public Policy, MRaimondi@ncuih.org 

About the National Indian Health Board (https://www.nihb.org/)
Established by the Tribes to advocate as the united voice of federally recognized American Indian and Alaska Native Tribes, NIHB seeks to reinforce Tribal sovereignty, strengthen Tribal health systems, secure resources, and build capacity to achieve the highest level of health and well-being for our People. 
Media Contact: Janee Andrews, Communications Manager, JAndrews@nihb.org

About the National Congress of American Indians (https://www.ncai.org/)
Founded in 1944, the National Congress of American Indians is the oldest, largest and most representative American Indian and Alaska Native organization in the country. NCAI advocates on behalf of tribal governments and communities, promoting strong tribal-federal government-to-government policies, and promoting a better understanding among the general public regarding American Indian and Alaska Native governments, people and rights. For more information, visit www.ncai.org.
Media Contact: Yawna Allen, yallen@ncai.org

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Health Resources and Services Administration Seeking Nominations for Membership to Serve on the Advisory Committee on Infant and Maternal Mortality

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On November 22, 2022, the Health and Resources and Services Administration (HRSA) issued a notice seeking nominations of qualified candidates for consideration to serve as members of the Advisory Committee on Infant and Maternal Mortality (ACIMM). ACIMM advises the Secretary of Health and Human Services (HHS) (Secretary) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants of women before, during, or after pregnancy. Written nominations for membership on the ACIMM must be received on or before January 23, 2022, and nomination packages must be submitted electronically as email attachments to Vanessa Lee, MPH, the ACIMM’s Designated Federal Official, at: SACIM@hrsa.gov. NCUIH strongly encourages UIO staff working in the areas of infant and maternal health to submit nomination materials.

Background

The ACIMM was established in 1991 and advises the Secretary on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. The ACIMM provides advice on how to coordinate federal, state, local, tribal, and territorial governmental efforts designed to improve infant mortality, related adverse birth outcomes, and maternal health, as well as influence similar efforts in the private and voluntary sectors. The ACIMM provides guidance and recommendations on the policies, programs, and resources required to address the disparities and inequities in infant mortality, related adverse birth outcomes and maternal health outcomes, including maternal mortality and severe maternal morbidity. With its focus on underlying causes of the disparities and inequities seen in birth outcomes for women and infants, the ACIMM advises the Secretary on the health, social, economic, and environmental factors contributing to the inequities and proposes structural, policy, and/or systems level changes. The ACIMM meets approximately four times per year, or at the discretion of the Designated Federal Officer in consultation with the Chair.

Nomination Eligibility and Information

HRSA is requesting nominations for voting members to serve as Special Government Employees (SGEs) on the ACIMM to fill open positions. The Secretary appoints ACIMM members with the expertise needed to fulfill the duties of the Advisory Committee. Nominees sought are medical, technical, or scientific professionals with special expertise in the field of maternal and child health, in particular, infant and/or maternal mortality and related health disparities; members of the public having special expertise about or concern with infant and/or maternal mortality; and/or representatives from such public health constituencies, consumers, and medical professional societies. Interested applicants may self-nominate or be nominated by another individual or organization.

Individuals selected for appointment to the Committee will be invited to serve for up to 4 years. Members appointed as SGEs receive a stipend and reimbursement for per diem and travel expenses incurred for attending ACIMM meetings and/or conducting other business on behalf of the ACIMM, as authorized by 5 U.S.C. 5703 for persons employed intermittently in government service

Nomination Package Materials

The following information must be included in the package of materials submitted for each individual nominated for consideration:

  1. A statement that includes the name and affiliation of the nominee and a clear statement regarding the basis for the nomination, including the area(s) of expertise and/or experience that may qualify a nominee for service on the ACIMM, as described above;
  2. confirmation the nominee is willing to serve as a member of the ACIMM;
  3. the nominee’s contact information (please include home address, work address, daytime telephone number, and an email address); and
  4. A current copy of the nominee’s curriculum vitae or resume. Nomination packages may be submitted directly by the individual being nominated or by the person/organization recommending the candidate.

Individuals who are selected to be considered for appointment will be required to provide detailed information regarding their financial holdings, consultancies, and research grants or contracts. Disclosure of this information is required in order for HRSA ethics officials to determine whether there is a potential conflict of interest between the SGE’s public duties as a member of the ACIMM and their private interests, including an appearance of a loss of impartiality as defined by federal laws and regulations, and to identify any required remedial action needed to address the potential conflict.

AI/AN Infant and Maternal Health

AI/AN communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. According to HHS’ Office of Minority Health (OMH), AI/AN infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Recognizing the infant and maternal health disparities that AI/AN people and communities experience, the HHS Secretary Xavier Becerra attended the White House Tribal Nations Summit on December 1, 2022, where he discussed the Department’s commitment to addressing mental and maternal health in AI/AN communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.  Given HHS’ current focus on addressing Native infant and maternal health, it is highly recommended that UIO staff submit applications to the ACIMM to ensure that the voice of urban Native communities continues to be heard in this work.

UIO and NCUIH work in AI/AN Infant and Maternal Mortality

UIOs provide a range of services such as primary care, behavioral health, and traditional, and social services— including those for infants, children, and mothers. Several UIOs provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive policy work on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s  MIECHV and doubling the Tribal set-aside— which includes UIOs.

Also, in March, NCUIH submitted comments to the ACIMM, and on September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the ACIMM on urban Indian disparities and policy changes to address these disparities.  Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.” Raimondi provided the following recommendations to the Advisory Committee:

  • Reauthorize MIECHV at a higher amount and double the Tribal set-aside from 3% to 6%.
  • ACIMM and other stakeholders should collaborate with UIOs to gather critical and accurate information on urban AI/AN populations.
  • Advise the HHS Secretary to lead the establishment of an urban confer policy across all HHS agencies.
  • Include a Tribal and UIO health provider representative on the ACIMM and create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities.

In August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

Furthermore, NCUIH recently released an infographic showcasing data on infant and maternal health disparities in American Indian/Alaska Native (AI/AN) communities.

 

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